ARMY MEDICAL LIBRABY

       WASHINGTON

          Founded 1836
Section.
Number
./.3J..£A.....&)
          Fobm 113o. W. D., S. G. O.
iro 3—10543   (Revised June 13, 1836)
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7/die A
AMERICAN CYCLOPEDIA
PRACTICAL MEDICINE AND SURGERY. 
 
"LIBRARY OF THE MEDICAL SCIENCES.
THE
AMERICAN CYCLOPEDIA
OP PRACTICAL
MEDICINE  AND  SURGERY
A DIGEST
               0F            s „Tx

MEDICAL  LITERATURE.
                      EDITED BY

                ISAAC  J^A Y S,  M. D.
SURGEON TO WILLS' HOSPITAL; PHYSICIAN TO THE PHILADELPHIA ORPHAN ASYLUM
      MEMBER OP THE AMERICAN PHILOSOPHICAL SOCIETY, &c. &c. &c.
VOL. II.
          iBhflatoeljriife:
CAREY, LEA, & BLANCHARD.
1836. 

  Entered  according to the act of Congress, in the year 1834, by Carey,
Lea, & Blancharo, in the clerk's office of the district court of the eastern
district of Pennsylvania. 
CONTRIBUTORS  TO  THIS  VOLUME.
FRANKLIN BACHE, M. D., Professor of "J
  Chemistry in the Philadelphia College of 1 Antidote ;   Antimony;   Aspartic Acid;
  Pharmacy, and Physician to the Peniten- j   Atomic Theory.
  tiary  ..............................J

N. CHAPMAN,  M.D., Professor of the In- 1
  stitutes and Practice of Physic and Clinical > Asthma.
  Practice in the University of Pennsylvania. j

REYNELL COATES, M. D...........   Ankle; Anthrax ; Anus ; Arm (Fract.).

D. F. CONDIE,  M. D.................   Apoplexy ; Ascites.

W. P. DEWEES, M. D., Late Professor of 1
  Midwifery in the University of Pennsyl- > Aphtha.
  vania.............................. ^

ROBLEY DUNGLISON, Professor of Mat. )  .   ,   .          ,    /rT1,
  Med., &c, in the University of Maryland. \ AsPhVxia i Atmosphere (Therap. and Hyg.)

E. GEDDINGS,  M. D.,  Professor  of Ana- ) Anthropology; Anthropotomy; Aorta ; Arm;
  tomy in the University of Maryland--- \   Arteries ; Atrophy; Axilla.
R. E. GRIFFITH, M. D., Professor of Ma-
of Pharmacy
Anise; Antirrhinum ; Apocynum; Aralia;
  Arctium ; Argemone ; Aristolochia; Aro-
teria Medica in  the Philadelphia College V   matics; Artemisia ; Arum ; Asclepias;
Aspidium ;  Asplenium;   Astragalus ;
Atropa.
SAMUEL JACKSON, M. D., Professor of
  the Institutes of Medicine in the Univer- !> Antiphlogistics; Arsenic (Therap.).
  sity of Pennsylvania...........
*f
J.  K. MITCHELL, M. D..............   Arsenic (Chem. and Med. Leg.)

R. M. PATTERSON, M. D. ...........   Atmosphere (Phys. Hist.)
GEORGE B. WOOD, M. D.,  Professor of
  Materia Medica  in  the  University of
  Pennsylvania  .......................
ISAAC HAYS, M. D., one of the Surgeons
  to Wills' Hospital, &c................
Angvstura Bark;  Anime; Anodynes; An-
  thelmintics; Anthemis; Antilithics; An-
  tispasmodics ; Apium ; Arbutus ; Areca;
  Arnica ; Arrow-root; Asarum ; Aspara-
  gus ; Assafetida ; Astringents,

Anorexia ; Anosmia ; Antaphrodisiac ; An-
  thrarcosis ;  Anti ;  Antipathy; Antipo-
  nodics ;   Antiscorbutics ;   Antiseptics ;
  Anus (Artificial  and  Imperforate);  Ape-
  rient ;  Aphonia; Aphrodisiacs; Appe-
  tence ;  Archaus; Arsenic  (Pharm. and
  Posol.); Asthma (of Millar) ; &c. 
 
THE
AMERICAN  CYCLOPEDIA
PRACTICAL  MEDICINE  AND  SURGERY.
ANGI.—ANGU.
   ANGIODESIS, or Angeiodesis. (From
 ayyiiov, a vessel, and 81 &$, demonstration.)
 Distension or swelling of vessels.  Condi-
 tion near to inflammation, according to
 TOMMASINI.                    I. H.
   ANGIOLEUCITIS, or  Angeioleuci-
 tis.  (From ayycvov, a vessel, and %ivxo$,
 white.)  Inflammation of the white ves-
 sels: Lymphatic  or scrofulous inflamma-
 tion : Subinflammation, of Broussais.
                               I. H.
   ANGIOSIS.  (From cvyystoi; a vessel.)
 Alibert has given this term to the sixth
 family, in  his nosology, and which com-
 prises all diseases seated in the blood-ves-
 sels.                           I. H.
   ANGIOTENIC, or Angeiotenic. (From
 ayyiwv, a vessel,  and  ttwtw,  to stretch.)
 Pinel invented this term to designate the
 condition  of the blood-vessels in certain
 fevers.  His order, angiotenic fevers, com-
 prises all  those  which exhibit, besides
 fullness and tension of the vessels, symp-
 toms of irritation of the arterial tunics :
 it is the Synochus imputris, Galen ; Sy-
 nocha simplex, et  acuta sanguinea, Hoff-
 man ; Febris continens vel synocha, Stahl ;
 Febris inflammatoria,  Stoll, &c. ; Sy-
 nocha, Sauvages, Cullen, &c.  (See Fe-
 ver.)                          I. H.
   ANGLE. (From ayxvtoj, a hook.) The
 inclination or opening of two lines, having
 different directions and meeting in a point.
 In anatomy, the epithet angle is bestowed
 on certain parts of bones and large mus-
 cles ; on the union of two branches of
 bones; on  the commissures of the eye-
 lids, and of the lips; on the union  of the
 facial and basilar lines (facial angle, q. v.),
 &c.                           I. H.
   ANGULAR.  That which appertains
 to an angle.                   I. H.
  ANGUSTURA BARK.—Angustura,
 Ph. U. S.—Angusture, Fr.; Angustura-
rinde, Germ.
  Vol IL
   Botanical History.   Nothing was cer-
 tainly known  of the source of this  bark
 till the annunciation, by Humboldt and
 Bonpland, of their discovery of the tree
 producing it,  These  travellers, when at
 Angustura, a town upon the banks of the
 Orinoco, in South America, received a
 specimen of the leaves of a tree growing
 in that neighbourhood, from which  the
 bark was said to be derived. A tree which
 they subsequently observed near Cumana,
 was believed by them to be the same, and,
 as it  appeared to  them not to belong to
 any known genus,  was ascribed to a new
 one, which they named Cusparia, distin-
 guishing the species by the title of febri-
 fuga.  A specimen of the plant was,  in
 the mean time, sent to Willdenow, who
 also considered its generic  characters  as
 distinct, but named it, in honour of one of
 the celebrated travellers, Bonplandia tri-
 foliata. This title was subsequently adopt-
 ed by Humboldt and Bonpland, and has
 been  recognized by the Edinburgh and
 Dublin Colleges as the name of the An-
 gustura bark  plant, while  the  London
 Pharmacopoeia retains the  original appel-
 lation of Cusparia febrifuga.  MM. St.
 Hjlaiue and  De  Candolle,  however,
 deny that the  genus is distinct, and are
 probably correct in considering it as iden-
 tical with Galipea.  They have accord-
 ingly  proposed for the plant the  name of
 Galipea Cusparia,  which has been adopt-
 ed by  some European writers.   But, after
 all, there is reason to believe that the  tree
 observed by Humboldt  and Bonpland  is
 different  from  that which  produces the
 Angustura bark, though belonging to the
same genus.  These authors were proba-
bly led astray by the imperfect specimen
which  they received of the true  plant.
According to  Dr. Hancock, who resided
in the country where the Angustura bark
is produced, the tree  yielding it differs 
2                           ANGUSTURA BARK.
strikingly in size from that described by
Humboldt and Bonpland, the latter be-
ing sixty or eighty feet in height, while
the former  never exceeds  twenty  feet
For the genuine tree, Dr. Hancock pro-
poses the name of Galipea officinalis; and
this has been recognized in the last edi-
tion  of the U. S. Pharmacopoeia.   There
can be little doubt of  the correctness of
Dr. Hancock's statement.  In relation to
the size of the tree, his account  is con-
firmed by the character of the bark found
in the market, which could not have been
derived from a large trunk.
   The Galipea officinalis of Hancock be-
longs to the class and order Diandria Mo-
nogynia, and  to the natural order Dios-
mea  of Lindley's Introduction.   It is a
small branching  tree,  of the  medium
height of twelve or fifteen feet, with an
erect  stem from three to five  inches in
thickness.  The leaves, which are alter-
nate and petiolate, consist of three  oblong
leaflets,  pointed at each end,  from six to
ten inches long, from two to four broad,
smooth and glossy, of a bright green co-
lour,  of a strong odour when fresh, and
supported upon short leafstalks. The flow-
ers are numerous, and arranged in termi-
nal and axillary peduncled racemes. They
are white, and have a peculiar unpleasant
odour.  The calyx  is bell-shaped, five-
cleft,  and inferior;  the corolla about an
inch long, composed of five unequal, ob-
long, obtuse, reflexed petals, united at the
base;  the stamens two, with five linear
leaflets which  may be  regarded either as
abortive stamens or nectaries.   The fruit
consists of five bivalve  capsules, each con-
taining two round black seeds, of the size
of a pea.  Two or three of the capsules,
and one  of the seeds in each capsule, are
often  abortive.
  The tree grows in great abundance in
the countries bordering upon the Orinoco
river,  at the distance of two hundred miles
or more from the ocean. It prefers a rich
soil, and  flourishes at the height of be-
tween six hundred and one thousand feet
above the level of the  sea.  According to
Hancock, it is called  by the aborigines,
Orayuri; by the Spaniards  and Creoles,
Cascarilla, or  Quina de Carony.
   Sensible properties,  composition,  &c.
Angustura bark is in pieces from two to
eight  inches long, or  even longer, from
half an inch to an inch and a half broad,
from  half a line to  two or more lines in
thickness, generally  thinner at the edges
in consequence of  having been cut  ob-
liquely from the tree, usually somewhat
rolled,  seldom quilled,  and  sometimes
nearly flat.  The outer surface is covered
with  a  light yellowish-gray  epidermis,
which is sometimes thick, soft, and spongy,
so that it may be  easily scraped with the
nail.  Occasionally, the epidermis is par-
tially wanting, when the colour is brown.
The inner surface is usually of a dull yel-
lowish-fawn colour, more  or  less rough
and splintery.   The bark is brittle, with
a  short resinous fracture, and affords a
pale yellow powder.  The odour is pecu-
liar, and  rather  disagreeable, becoming
weaker by age.   The  taste is bitter and
slightly aromatic, leaving a sense of pun-
gency at the end of the tongue. The con-
stituents of the bark, according to Fisch-
er, are volatile  oil, bitter extractive, a
hard and bitter resin, a soft resin, a sub-
stance analogous to caoutchouc, gum, lig-
nin,  and salts.  The active principles are
probably the volatile oil  and  bitter ex-
tractive.  The bark yields its virtues both
to water and alcohol.
   Medical properties and therapeutic ap-
plication.  Angustura bark is  a stimulant
tonic, capable, when given  in large doses,
of producing an emetic and cathartic  ef-
fect.  It has long been employed in South
America, but was  not brought to Europe
till the  year 1778, when a portion  of it
reached England from  the West Indies,
into  which its use had been  introduced
from the  neighbouring continent.   It  at-
tracted  considerable attention  from  phy-
sicians,  and the reports in its favour were
such, that it soon became officinal through-
out Europe and America. Its virtues were
supposed to be the same with those of Pe-
ruvian bark; and  it was particularly  re-
commended in intermittent fever, bilious
diarrhoea, and obstinate dysentery. It was
also  found useful in dyspepsia, and other
complaints attended with  weakened  di-
gestion  or general debility.  But the  fa-
vourable results of the first  trials have not
been fully confirmed by subsequent expe-
rience.  The remedy has repeatedly failed
in the cure of intermittent fever; and, in
other cases in which tonics are indicated,
has not been found superior to the medi-
cines previously in use. It  has, therefore,
of late,  been very  much neglected, and
in this  country is seldom prescribed.  It
may, perhaps, be  more efficacious in the
complaints of tropical latitudes  than  in
those which prevail in temperate regions.
Dr. Hancock  speaks  in  the strongest
terms of its efficacy in numerous cases of
malignant bilious fever, dysentery, and
dropsy, which came under his notice  in
Angustura and Demarara.   He found it,
in these complaints, greatly  superior to 
TURA BARK.  (False.)
0
Peruvian bark. It is asserted to have this
advantage over the latter remedy, that it
is less apt to oppress the stomach.
  Dose and preparations.  The bark may
be administered in powder, infusion, tinc-
ture, or extract  The dose of the powder
is from ten to thirty grains, repeated every
three or four  hours through the day.  In
larger quantities, it is apt to produce nau-
sea.   The extract may be given in the
dose of from  five to fifteen grains,  but  is
said to be inferior to the powder or infu-
sion.   The  latter  is prepared  by  mace-
rating half an ounce of the bruised bark
in a pint of boiling water (Ph. U. S.), and
may be given in  the quantity of a wine-
glass-full, repeated several times a day.
The dose of the tincture, which is  offici-
nal, is one or  two fluidrachms.
  Dr. Hancock employed a fermented in-
fusion prepared nearly in the manner di-
rected by the native doctors.   Into a jug,
containing  about six gallons,  he  put a
pound of the  coarsely powdered bark, the
same quantity of brown sugar,  and about
four ounces of wheaten bread  to  hasten
the fermentation; then filled the vessel
nearly with boding water, stopped it close-
ly, and placed it  in  the sun, taking care
that it should be frequently shaken.  So
soon as fermentation had well commenced,
the preparation was considered fit for use,
and given in  the quantity of from four to
six ounces, three or four times a day.
  Bibliography.—Ewer.  London Med. Journ.
 1789, p. 154; 1790, p. 38.
  Meyer. De Cortice Angustura. Gotting. 1790.
  Brande.   Experiments  and observations on
the Angustura bark.  London, 1791, in 8vo.
  Filter.  Diss, de Cortice Angustura ejusque
usu medico.  Jena, 1791.
  Winterbottom.  Some observations relative
to the Angustura  bark.  Medical Facts, 1797.
VII. 41.
  Bornitz. De Corticis Angusturapalrih,prin-
cipiis, usugue medico.  Utrecht, 1804.
  Hancock.  Observations on the  Orayuri or
Angustura bark tree.  Med. Bol.  Soc. Transact.
—republished  in Journ.  of the  Phil.  Col. of
  ANGUSTURA BARK (False).
  Under the name of false or ferrugin-
ous Angustura, a bark has recently at-
tracted some attention  in Europe, on ac-
count  of its poisonous  properties.   It is
said to be taken to that continent  mixed
with the genuine, and to have been some-
times administered for it by mistake, with
dangerous and even fatal effects.  I have
never met with it in the parcels of An-
gustura which have  come under my no-
tice in this country; yet it is important to
be acquainted with its distinguishing pro-
perties, in order to be guarded against the
danger of its possible introduction into our
shops.   When first noticed, it was sup-
posed to be the product of the Brucea an-
tidysenterica, and was afterwards referred
to the  Strychnos colubrina; but  the  for-
mer is an  Abyssinian, the latter an East
India tree; while the bark is now known
to be  derived from  South America.   Its
precise source is entirely unknown.
  The false Angustura bark is  thicker,
harder, heavier, and  more compact than
the genuine ;  its external surface, or epi-
dermis, is destitute of lichens, which are
frequently found on the other, and  is either
covered with a rust-coloured efflorescence,
whence the name of ferruginous Angus-
tura was derived, or presents a yellowish-
gray colour with numerous  elevated whi-
tish spots; its internal surface is  smooth;
its fracture dull and brownish, and wholly
destitute of a resinous  appearance;  its
powder is yellowish-white;  it is destitute
of odour; and its taste, though excessive-
ly bitter, and in this respect much exceed-
ing that of the genuine, is neither pun-
gent  nor aromatic.   Nitric acid produces
a blood-red colour when dropped upon the
internal surface of the spurious bark, and
an emerald-green colour upon the epider-
mis or efflorescence  on the external sur-
face, while it yields a dull red on both sur-
faces  of the true.
   Pelletier and Caventou discovered in
the false Angustura a peculiar  alkaline
principle denominated brucia, which has
been  subsequently found in the nux vo-
mica and bean of St. Ignatius. (See Nux
vomica.)   Upon this principle, the poison-
ous properties of the bark depend.
   From the experiments of Orfila and
others, it  appears that the false Angustu-
ra, administered to animals, in  the form
of powder  or extract, acts  in the same
manner as the nux vomica,  producing vio-
lent  tetanic convulsions, which  speedily
end in death.  Eight grains of the bark,
given to a dog of middle size, proved fatal
in the course of an  hour and a quarter.
 The same effect  resulted from the intro-
duction of the powder or extract into the
cellular membrane of the thigh.   Dissec-
 tion revealed no marks of inflammation,
 and the poison was supposed to  act upon
 the nervous system, and principally upon
 the spinal marrow. Emmert relates a case
 in which the bark was administered as a
 tonic,  to an infant, by mistake for the ge-
 nuine  Angustura,  and occasioned death,
 with frightful convulsions.   It is not em-
 ployed as a medicine, although,  from the
 resemblance  of its  action to that  of nux 
4
ANH.—ANIS.
 vomica, it might probably be serviceably
 and safely applied to similar cases, if its
 dose were accurately ascertained. A case
 is related in  the Journ. Univ. des Sci-
 ences  Med. IX.  118.,  in  which twelve
 grains of the  bark, given twice a day, to
 a patient affected with obstinate intermit-
 tent frontal neuralgia,  produced a cure,
 though not  without  dangerous  evidences
 of its  powerful action, such as  vertigo,
 and convulsive tetanic movements.
                      Geo. B. Wood.
  ANHELATION..  (From  anhelo,  I
 pant.)  Anhelatio, Lat; Essoufiement, Fr.
 Short and difficult respiration. (See Dysp-
 noea.)   Sauvage has made this  the char-
 acter of one  of  his  classes  of diseases.
 This term has sometimes been employed
 synonymously with Asthma (q. v.). I. H.
  ANHISTOUS. (From a priv. and veto;,
 tissue.) Anhiste, Fr.  Without texture.
  Anhistous membrane.  This term  has
 been given  by M. Velpeau to the mem-
 brana decidua.   Embryologie, p. 7.  (See
 Ovum.)                         I. H.
  ANHYDROUS.   (From a  priv. and
 v$o>e, water.) Containing no water. Those
 salts are termed anhydrous which contain
 no water of crystallization.       I. H.
  Animal Contagion. (See Contagion.)
  Animal Heat. (See Calorification.)
  ANIMALCULAR.   Appertaining to
 animals.                        I. II.
  ANIMALCULE.   (Diminutive of ani-
 mal.)  An animal perceptible only with
 the aid of a  microscope.          I. H.
  ANIMALITY.   The  attributes  and
 properties of animal organic matter.
                                I. H.
  ANIMALIZATION.  The conversion
 of vegetable substances into animal mat-
 ter. It is the compound product of several
 successive elaborations of matters  des-
tined for nutrition, effected in the animal
 economy,  before they are assimilated and
 applied to  the reparation of  the  body.
 (See Digestion, Assimilation, and Nutri-
 tion.)                           I. H.
  ANIME.—Gum Anime.—Animee, Fr.;
 Anime, Germ.
  The substance known by this name is
a resinous product  brought  from South
 America, and generally supposed to be de-
rived from the Hymenaa Courbaril, though
this origin  is  not undisputed.   It  is in
small irregular pieces, of a pale yellow
 colour  sometimes  inclining  to  reddish,
more or less transparent brittle and pul-
 verizable,  of a  shining fracture, of a weak
agreeable  odour rendered stronger by heat,
and of a mild resinous taste.  It softens
 in the mouth, adheres to the fingers when
in the state  of powder, and melts with a
moderate heat. It consists of two distinct
resins, one soluble, the other insoluble, in
cold alcohol, and of a small proportion of
volatile oil. Other varieties of Anime are
described in the books, but are at present
scarcely known in commerce.   This resin
was formerly employed in pharmacy as an
ingredient of ointments and plasters;  but
is at present used only as  incense, and in
the preparation of varnishes.   It is said to
be' employed internally, in Brazil, in com-
plaints of the lungs.   Geo. B. Wood.
  ANIMISM.  (From anima, the soul.)
This epithet has been usually employed to
designate the doctrine of  Stahl, who re-
ferred  all  the  phenomena of  the  animal
economy to the soul.  But it has been very
justly observed by M. Dezeimi.ris, that
we  ought  to  understand by  that term,
every physiological doctrine which, to ex-
plain the phenomena  of life, supposes the
existence, in organized bodies, considered
as inert of a principle of action, existing
of itself, and whose office it is to animate
them.  It is wrong, then,  to restrict this
term to designate the doctrine  of Stahl ;
it is doubly  erroneous, for, on the one
hand, Stahlianism, considered  relative to
its hypothesis of the first causes of life, is
but a particular form of animism; and an-
imism, on the other hand,  is far from em-
bracing entirely, the  comprehensive doc-
trine of the professor of Halle.  (See Vi-
talism.)                         I. H.
  ANISE, or ANISEED. (Mat. Med.)
Anisum, U. S. Ph.; Anis, Fr., Germ.
  Aniseed is  the  product of  an annual
plant (Pimpinella  anisum) indigenous to
the countries bordering "on the  Mediterra-
nean, and  which  is cultivated  in many
parts of Europe.  Several  kinds are found
in commerce : 1. that from Russia, which
is small, blackish,  acrid, and but little es-
teemed :  2. that from Touraine, which is
green,  and much milder:  3. that from
Albi, which is lighter coloured, and more
aromatic: and, 4. that from  Spain and
Malta; this is  the variety generally met
with in the shops.  It consists of small ob-
long striated capsules, of an ash-green co-
lour, and  containing two  seeds, attached
to each other by a  flat surface.  They pos-
sess an aromatic and pleasant taste, and a
fragrant odour.  These properties depend
on a volatile oil which appears to reside
in the integuments,  in the proportion of
about one ounce of oil to three pounds of
seed.  This oil, which is obtained by dis-
tillation,  is transparent, and concretes at
59° F.   It imparts its sensible properties
to boiling water, though sparingly, but is 
ANKLE.  (Surg. Anat.)
readily soluble in alcohol. By expression,
a fixed oil is also obtained, which is a mix-
ture  of a  mild,  inodorous  fat oil,  with
a  small portion  of the  volatile oil just
spoken of.
   Aniseed is much employed in Europe,
as  an  aromatic  carminative,  more espe-
cially in  domestic practice,  in flatulent
colic,  and as a corrective  of the griping
occasioned by many of the drastic purga-
tives.  In this country, less use is made of
it,  its place being supplied by more effi-
cient articles.
   It may be given, in substance, in doses
of twenty or thirty grains, or  in infusion;
this latter form,  however, should be dis-
carded, as inefficient.  The neatest mode
of administration  is the volatile  oil,  of
which the dose is from five to ten drops.
It should be noticed that much of the  oil
of aniseed of our shops,  is the product of
the Illicium anisatum (q. v.), and is supe-
rior to that of the Pimpinella.
   The principal  consumption of aniseed
is in domestic economy, to flavour confec-
tionary and cordials.
  Bibliography.—Merat and De Lens.  Art.
Anisum. Diet. Univ. de Mat. Med. I. 308.  Pa-
ris, 1829.
  Alibert.  Nouveaux elimens de thirapeutique,
&c. II. 530.  Paris, 1806.
                       R. E. Griffith.
   ANKLE.  The surgical acceptation of
this term  has never been very accurately
defined. In ordinary language, it is some-
times employed as synonymous with mal-
leolus, and, at  others,  it is applied more
generally, to the  articulation between the
bones of the leg and the astragalus.  The
latter application  appears to be adopted by
many surgeons,  whUe  others give still
greater extension to its  signification.  It
seems to us almost a matter  of necessity
to  include  under this head all those parts
which are immediately connected with the
several  motions  performed  by the  foot,
viewed in its totality,  upon the leg; for,
otherwise, it is extremely difficult to give
a clear account of many of the accidents
and injuries involving what is universally
called the ankle joint.
   The ankle, then, viewed  as a region,
includes the two malleoli, with so mu'ch
of the lower extremities  of the tibia and
fibula  as are interested in the inferior ar-
ticulation  of those bones; the  astragalus
and its several articulations with the leg,
the os  calcis, and the os scaphoides; the
ligaments  of all these  articulations; and
the various  soft parts that surround the
limb between the  superior surface  of the
os calcis,  the  posterior  edge of the  os
                   1*
 scaphoides, and the  summit  of the parts
 accessory to the lower articulation of the
 tibia and fibula.
   With the soft parts last mentioned, we
 have little concern in the present article ;
 the details of their anatomy will be found
 in  the appropriate general articles;  and
 the accidents  and diseases to which they
 are liable will be  described under  the
 same or other  heads. (See Tendon, Bursa
 Mucosa, Artery, &c.) Many  of the affec-
 tions of the joints and bones, not in their
 nature peculiar to the ankle,  are  also re-
 ferred to the articles on Bones, Necrosis,
 &c.
   Art. I.   Surgical Anatomy  of the
 Ankle. Referring elsewhere for most of
 the details relating to the bones and liga-
 ments which form the ankle  and  its arti-
 culations (see  Bones, and Articulations),
 we propose to confine ourselves, in the pre-
 sent article, to  a rapid view of some impor-
 tant generalities which form  a necessary
 introduction to the  subjects which  we
 shall have presently to discuss.
   The inferior articulation of the  fibula
 with the tibia,  is  scarcely capable of any
 motion; yet it is provided with articular
 cartilages, lined by a production in cul de
 sac of the synovial membrane of the an-
 kle joint.  Numerous and powerful liga-
 ments  connect the opposite  bones with
 each other, so  that in severe injuries the
 ligaments  are rarely ruptured;  for  the
 fibula is frequently broken by forces too
 slight to tear them,  and sometimes  the
 tibia itself gives way before the articular
 connexions yield, leaving a portion  of its
 lower extremity still attached to the fibu-
 la.  The internal side of the fibula is here
 somewhat  convex, and is received into a
 slight longitudinal groove in the external
 side of the lower extremity  of the  tibia,
 which structure gives material protection
 to  the  articulation against injury in vio-
 lent rotations of the foot
   The deep hinge-like cavity for the re-
 ception of the  articular pulley of the as-
 tragalus is thus  formed.  The  superior
 face of the pulley is  directly opposed to
 the inferior extremity of the tibia.  A pro-
 cess from the  latter,  called the internal
 malleolus, is continued downward for some
 distance, and stands opposed to the inter-
 nal lateral face of the pulley. The fibula
 is continued downward for some distance
 below its inferior articulation  with the ti-
 bia, and is enlarged at the same time into
a kind  of head called the external  mal-
leolus.   The greater part of the internal
surface of this malleolus stands opposed to
the  external side of the  pulley  of the 
6                           ANKLE.  (Mechanism.)
astragalus;  the remainder is prolonged
downward and somewhat backward, into
a kind of hook for the protection of a ten-
don ; and this prolongation may be brought
into contact with the external face of the
os calcis, in violent abductions of the foot.
The external descends much lower than
the internal malleolus, and it is also situ-
ated further back.  The cavity for the re-
ception of the pulley is considerably en-
larged in rear by the posterior transverse
ligament of the ankle joint a band of very
strong arched fibres stretching from one
malleolus to the other along the posterior
margin of the inferior extremity of the
tibia. Into this complex cavity the pulley
of the astragalus is received, and all the
opposing surfaces of the bones are cover-
ed with articular cartilages.  The joint is
secured by numerous ligaments, and has
one  synovial  membrane  common to the
whole of this and the preceding articula-
tions. In order to comprehend all the mo-
tions  of the foot upon the leg, it must be
remembered that the pulley of the astra-
galus is considerably narrower behind than
it is before;  hence, when the foot is flex-
ed, the articular cavity is completely filled
by it, and the motion of the  joint is re-
duced to a simple flexion and extension;
but when the foot is extended, the cavity
is  not so fully occupied,  and  some slight
lateral motion of the astragalus may take
place.   The  interlocking  between  the
groove in the upper face of the pulley of
the  astragalus,  and the  corresponding
ridge of  the tibia, together with the tonic
contraction of the powerful muscles of the
foot, and  the position of the ligaments of
the articulation, deprive  the  joint of all
voluntary motion except that  of a simple
hinge; and it is only under the action of
accidental forces, that  it assists in the la-
teral or rotatory movements of the foot
  The ligaments of the ankle joint are all
highly important in a surgical point of
view, and their connexions must be care-
fully studied by those who would perfectly
comprehend the accidents to which the
joint is subject.
  The astragalus rides upon the os calcis,
and fills  the cavity of the os naviculare,
between which bones, and those of the leg,
it acts somewhat in the manner of a fric-
tion wheel, as we shall see hereafter.  On
its lower or plantar  face, we observe  a
very deep groove, commencing near the
posterior end  of its internal margin, and
passing forward and a little outward, so as
to  divide its lower articular surface into
two nearly equal parts.  Directly beneath
this, is a similar groove on the upper face
of the os calcis, which, with the former,
completes  an irregularly elliptical canal.
beginning  below the posterior edge of the
internal malleolus, and terminating a little
behind, and beneath the middle of, the an-
terior margin of the articular pulley. This
canal is filled by a  very powerful interos-
seous ligament, which is never completely
ruptured except  under  the action of tre-
mendous forces.
  Behind and on the outside of the  inter-
osseous ligament, we find the posterior or
external  articulation, between the astra-
galus and the os calcis.  It is arthrodial in
character,  the  head being formed by the
latter bone, and  presenting  upwards and
forwards.   The excavation in the astraga-
lus which  receives this head is of a lu-
nated shape, and  is  surrounded by a rather
sharp edge  which posteriorly is particularly
well defined. Its centre corresponds with
the level of the apex of the internal malle-
olus. This  joint enjoys an antero-posterior
motion in walking, in which case the astra-
galus moves upon the os calcis;  a lateral
motion in the adduction  and abduction of
the foot, during which the former bone re-
mains at rest; and a very slight degree of
rotation.   A proper synovial membrane is
exclusively provided for this articulation,
which  derives  its  strength  chiefly  from
the interosseous ligament noticed above.
  The articulation  of the head of the as-
tragalus with the tarsus, is an enarthrosis.
The cavity of the joint is formed, behind,
by the lunated cavity of the  os calcis, for
its  anterior or  internal articulation  with
the former  bone; before, by the concavity
of the posterior face of the os scaphoides;
and beneath, by the  two calcaneo-scaphoid
ligaments.
  All the parts  interested in this  articula-
tion are lined by a common synovial mem-
brane.   The motions of the joint like all
those of a similar structure, are limited in
extent only, ivnd not in direction; in con-
junction  with  the  posterior articulation
between  the astragalus and os  calcis,  it
permits the adduction, abduction, and ro-
tation of the whole foot on the  leg; in
conjunction with  the articulation between
the os calcis and the cuboid bone,  it enjoys
other powers, unconnected with  our pre-
sent subject  (see Foot); but it also con-
tributes slightly to  the flexion and exten-
sion of the foot,  and  this fact is of high
surgical importance, as will be elsewhere
noticed.
  Art. II.   Mechanism of the Injuries
of the Ankle.  Most of the peculiar inju-
ries of the ankle joint result from undue
and violent extension of some of the na- 
ANKLE.  (Mechanism.)                           7
tural  motions of the part.  They may be
enumerated  in the  order of their impor-
tance, as follows:  Sprains, or contortions
of the ankle; diastasis of the inferior ar-
ticulation of the tibia and fibula; fractures
of the bones of the leg, involving the an-
kle joint, or influencing its functions; and
dislocations  of the  foot.   Until recently,
the mechanism of these accidents has been
very  imperfectly described;  and it is in-
dispensably necessary that the nature of
the several  motions of the foot should be
fully understood, in order to their proper
comprehension.
   When all the muscles of the foot are in
a state  of relaxation, as in sleep, the to-
nicity of the extensors and adductors over-
comes that  of the  flexors and abductors,
so that  the  toes point downward, and the
sole  of the foot is turned a little inward ;
but the abductors are inserted at a greater
distance from the centre of the joint than
their  antagonists,  and thus enjoy  a me-
chanical advantage which, when they are
called into action, gives the foot a tenden-
cy to evertion.  This would render the
joint  extremely liable to injury, were it
not for the resistance of the elongated ex-
ternal malleolus, which furnishes the ne-
cessary  counteracting force  by its pres-
sure  upon the side of the astragalus.  The
toes  are naturally  pointed  outward, in
 consequence of the position of the exter-
 nal, in rear of the internal malleolus; but
 if all the intertarsal articulations remain
 fixed, the natural  invertion or additional
 evertion of the  toes is limited to  an ex-
 ceedingly slight rotation, performed by the
 astragalus, and permitted by the scarcely
 perceptible mobility of the lower articula-
 tion  between the tibia and fibula.  Even
 the articular connexions of the astragalus
 with the other tarsal bones,  cannot mate-
 rially facilitate the invertion or evertion
 of the toes, unless the sole of the foot is
 permitted,  at the  same time, to present
 itself inwardly or outwardly; because the
 astragalus  cannot  rotate itself upon the
 ossa  calcis and naviculare horizontally, or
 around  a perpendicular axis; for  all its
 movements upon the tarsus,  except those
 of simple  flexion  and  extension  of the
 foot, are orbicular and complex.  If, then,
 the  whole foot becomes suddenly  fixed,
 and  the leg is at the same time forcibly
 twisted, or  vice versa, the chief part of
 the force is exerted in turning the pulley
 of the astragalus within the  ankle joint.
 Now this must evidently tend to throw
 the  malleoli asunder,  and will produce  a
 Bprain of the ankle, and of the tibio-fibu-
 iar articulation; a  diastasis of the latter;
or a fracture of one or both malleoli, with
consecutive dislocation of the foot; accord-
ing to the nature and violence of the force
applied.
   When  the weight  of the body rests
upon  the  feet, it is the outer side of the
tarsus, and the tuberosity of the os calcis,
only,  that approach the soil;  the  remain-
der of the dome, and the inner side of the
arch of the  tarsus, remain  considerably
elevated,  and  the  whole  support of the
foot, on this side, depends upon the ball of
the great toe.  Now, if a line be drawn
from the tuberosity of the os calcis where
it rests upon the  ground, to the ball of the
great toe, subtending the plantar arch, it
will be found to fall very considerably to
the outside of the  middle line of the an-
kle joint,  so that the  joint overhangs the
base on which the  foot is supported upon
the inner side.  It follows from this  posi-
tion,  that the weight of the body tends
constantly to bring the inner edge of the
foot toward the ground, or to produce ab-
duction; a tendency considerably increased
by the oblique position of the leg, which
inclines inward from the knee to the an-
kle. If the internal lateral ligament were
left to oppose this disposition to abduction,
without  additional aid, the  protection  to
the joint would  be very  inefficient; but
the elongation of the external  malleolus
secures the  astragalus  in its proper posi-
tion,  in  all  the  ordinary attitudes of the
body.  On the contrary, when,  in  falls
from a height, upon a  plane surface,  or in
sudden missteps, the momentum of the body
is substituted  for its  simple weight the
abduction of the foot is often carried be-
yond its natural limits,  and  gives rise  to
accidents, grave in proportion to the ex-
tent  of the fall  and  the position of the
body at the moment.
   In the healthy  condition of the parts,
the lateral motions of  the  foot are per-
formed independently of the astragalus,
which retains constantly the same  posi-
tion, if we  except a  very slight rocking
motion permitted by  the yielding of the
ligaments.   Adduction and abduction are
 chiefly accomplished by the double articu-
 lation of the astragalus with the os calcis
and os scaphoides:  the nature of the mo-
tion will  be easily understood by reference
 to the skeleton, though it hardly admits
of description.   The  anterior part of the
 foot may be  rotated much further than the
 posterior, in consequence of the  complex
 motions of the various bones of the tarsus
 and metatarsus (see Foot); but these mo-
 tions  are foreign  to  the present article.
 The  natural extent of abduction is  more 
8
ANKLE.   (Mecnantsm.)
limited than that of adduction.  When
forcibly carried beyond its proper limits,
the first effects are as follows: The inter-
nal lateral, or deltoid ligament is put upon
the stretch; the  head  of the astragalus
sinks  deeply  into the  socket,  pressing
down, or flattening,  the arch of the  tar-
sus, and tending strongly inward against
the lateral portion of the inferior  calcanec-
scaphoid ligament; while the cuboid  and
scaphoid bones, following the motions of
the front part of the foot, are rotated some-
what upward, so as to become prominent
on the back of the foot  As the head of
the astragalus  cannot become primarily
dislocated inward or downward,  in conse-
quence of the great strength of the liga-
ment just mentioned, the abduction cannot
be carried any further by the inferior  ar-
ticulations  of the astragalus, and the  ab-
ducting force  then tends to twist or to
evert the whole of this bone in the ankle
joint causing it to react strongly on  the
external malleolus, and  putting upon  the
stretch the ligaments of the inferior tibio-
fibular articulation.  This accident may
produce severe sprains  in the ankle pro-
per, in the joint last mentioned, and in  the
articulation  between the astragalus and
the os scaphoides: all the other  joints of
the tarsus partake more or less  in  the in-
jury when the case is serious.
  In  falls from a great height,  the mis-
chief does not stop here. The astragalus
is forced still further from its erect posi-
tion ;  the deltoid ligament is partially or
completely torn or separated from  its  at-
tachments ; or, as  sometimes happens, this
very firm band of fibres tears off the  in-
ternal malleolus.  The momentum  of  the
body now acts with great force upon  the
external malleolus, which descends upon
the side of the astragalus, comes in con-
tact with the os calcis, and is forced vio-
lently outward.   The ligaments  of the ti-
bio-fibular articulation may yield in some
very  rare  cases,  and a diastasis of this
joint  is the consequence. One instance is
recorded by Boyer, in which there was a
complete separation of the fibula at both
extremities. (Mai. Ch.  IV. 375.)  More
frequently,  the ligaments just  mention-
ed tear off a portion  of the tibia, which
remains attached to  the lower extremity
of the fibula (see Sir A. Cooper,  on Frac-
tures  and Luxations); but  a much more
common result  is a fracture of the latter
bone above the joint, at some point within
three inches of its extremity.  This frac-
ture generally results from an increase of
the natural curvature of the bone, pro-
duced by the pressure  acting upon  the
malleolus.  Even when the tibia and fibula
are not separated, this accident produces
an unnatural tendency to abduction of the
foot, from the mobility of the lower frag-
ment of the fibula, and the consequent loss
of proper lateral support from the  malleo-
lus : a partial luxation is the result, which
will continually recur unless  proper me-
chanical measures are employed  to  pre-
vent it. This may be  regarded as a sprain
of the ankle complicated with fracture of
the fibula.  The same state of things often
occurs without a sprain, when the fibula
is broken by direct  external force  near
the ankle joint.  But even when diastasis,
or partial fracture  of the tibia, occasions a
separation of the bones, the fibula must be
generally broken  consecutively,  because
the external malleolus is still driven out-
wards, while the body of the bone is kept
in proximity to the tibia by the interosse-
ous ligament of the  leg, which exceeds
the bone in its powers of resistance.   Un-
der such circumstances, a luxation of the
foot is the  inevitable consequence.  The
farther complications and treatment of this
accident will be mentioned when we reach
the subject  of luxations of the foot
   If,  in such  falls as we have been con-
sidering, the foot  impinges upon  an un-
even surface, which happens so to support
the inner edge of the tarsus as to prevent
the abduction,  the  force is chiefly expend-
ed upon the horizontal articular surface of
the tibia, and the lower extremity of this
bone  may  be fractured or  comminuted.
The pulley of the  astragalus,  driving be-
fore it the fragments of the tibia, then as-
cends between the bones of the leg,  and
may produce a  variety of accidents, ac-
cording to  the direction of the force ap-
plied.   The fibula  may yield at the same
time,  near  its  lower  extremity, so as to
produce what has been  called luxation
outward and upward.
   I have seen the fibula ruptured three
inches, and the tibia two inches above the
ankle, the  lower extremity of the latter
being comminuted  on its outer side; yet,
from the size and  interlocking of  the in-
ternal fragment, and the integrity of the
lateral ligaments, the derangement of the
foot was very slight and the only per-
manent deformity  was  a trivial shorten-
ing of the limb.  The man died of fever,
seven weeks after the accident and a pre-
paration was made of the part.  The ar-
ticulation between the bones  of the leg
retained its integrity in a great degree, for
the lower interosseous ligament preserved
its attachment to the fragment of the ti-
bia, but the central portion of the lower 
ANKLE.  (Mechanism.)                           9
extremity of that bone was driven into the
cancellated structure, with its cartilagin-
ous covering.
  Invertion or adduction of the foot is ef-
fected by the motions of the os calcis and
the os naviculare, upon the astragalus.  It
is more extensive than the abduction. We
have  already  mentioned  the position as-
sumed by the  foot when the muscles are
perfectly relaxed.  When persons are ha-
bitually careless in walking, this state of
relaxation is  very apt  to  occur, and the
consequences  are often serious. The outer
edge  of the foot presents downward, and
is thrown so far inward that the centre of
the ankle joint overhangs it upon the outer
side.   If an inadvertent step be taken  in
this position, the whole weight of the body
tends to increase the adduction, and car-
ries it far beyond its natural limits.   The
entire tarsus rotates strongly inwards, the
os naviculare  sinks from its proper level,
and the head of the astragalus becomes
very prominent upon the dorsal surface of
the foot.   The  interosseous ligament be-
tween this bone and  the os calcis is forci-
bly stretched, and the injury it sometimes
sustains is one of the most important con-
sequences of  the  accident.  As this liga-
ment is immensely powerful, it soon puts
a check to the motion of the astragalus
upon  the  os  naviculare,  and  prevents it
from  luxating upward.  The action of the
weight of the body is then transferred to
the ankle joint; the lower surface of the
astragalus endeavours to follow the os cal-
cis, and the upper face of the pulley is di-
rected outward. The external lateral liga-
ments  are unduly stretched, and great
pressure is exerted  on the internal con-
dyle.  Hence result severe sprains of the
ankle joint, (which, however, do  not in-
volve the  tibio-fibular articulation,) and
severe injury to the interosseous ligament
of  the calcis  and astragalus, which some-
times gives rise to white swelling and an-
chylosis.  If  the  force exerted is very
great,  the internal  malleolus may give
way, and the  fibula may be broken by the
traction of the three peroneo-tarsal liga-
ments ;  for the  strength of these bands is
so great that they are scarcely ever rup-
tured, but the malleolus is obliged to follow
them in their displacement.  Under these
circumstances,  the foot is inevitably dis-
located.   The worst cases of this charac-
ter occur in falls from a height,  when the
foot is suddenly arrested, and the body in-
clines toward the opposite side, without
receiving the support of the  other foot
   In  accidents producing  forcible flexion
of the foot, the front edge of the extremity
of the tibia comes into contact with the
neck  of the astragalus, before the poste-
rior edge has reached the summit  of the
pulley; hence, a  dislocation  of the  foot
forward is rendered extremely difficult, if
not impossible.  Moreover, the articula-
tions of the astragalus with the other tar-
sal bones, are arranged in such a manner
that this bone has very little  tendency to
become displaced  backward upon  the os
calcis; on  the contrary,  it  is pressed
forcibly downwards;  and if the force of
the fall is very great, the tibia will yield
before any other very serious consequence
results.
   The  forcible  extension of the  foot is
productive  of more complex, as well as
more serious, consequences. These might
be explained, a priori, by a thorough ana-
tomist well versed in the application of
the known laws of mechanics; but they
have  received additional elucidation from
the experiments of Dr. Rognetta. (Ar-
chives Generates,  Dec. 1833.) When the
extension begins to pass the natural bound-
ary of motion, the anterior ligament of the
ankle  is distended,  and a sprain  of this
joint is the consequence.  The head of the
astragalus rises in its socket at the same
time, and the interosseous ligament is ex-
tended, producing a sprain of this  part
also.  If the extension is still continued,
the posterior edge of the inferior extremi-
ty of the tibia  approaches the lower edge
of the astragalus;  the pulley ruptures the
front part of the capsular and anterior li-
gaments, and  becomes partially luxated
forward.  If carried  yet  further, the ex-
ternal malleolus descends upon the outer
face of the posterior part of the os calcis,
where it is driven outward with so much
force as to produce  a sprain, and some-
times a diastasis  of its articulation with
the tibia, and, consecutively, a fracture of
the  bone itself, somewhere within three
inches of the malleolus.   If the force  is
still unexpended, the tibia continues to act
as a lever upon the astragalus, its poste-
rior edge urging the back part of this bone
forward upon the os calcis, while the re-
mains of its anterior, and part of its del-
toid ligaments, elevate the  head  of the
bone until  the resistance  of the interosse-
ous  ligament is partially overcome; the
weak astragalo-scaphoid ligament gives
way, and the head of the astragalus is dis-
located upward and forward on the back
of the tarsus.  A slight lateral force is now
sufficient to carry the head of the bone in-
ward  or outward, toward either edge of
the foot so as to produce consecutive dis-
locations of the astragalus, which cannot 
10
ANKLE.  (Sprains of.)
under any circumstances occur primarily.
The interosseous ligament is never com-
pletely broken in  these  accidents, unless
the momentum of the body is added to the
simple lever-like action  of the tibia.  In
falls from a height, when the foot is com-
pletely arrested,  it  sometimes  happens
that the tibia slides forward over the ar-
ticular pulley, and the foot is partially or
completely dislocated backward,  the as-
tragalus remaining in situ.   When this
rare consequence does not follow, the im-
pulsion of the body is transmitted to the
last mentioned bone, which is chased for-
ward by the tibia, until, after the complete
separation of the interosseous ligament it
is entirely disembedded.  (See Astraga-
lus.)   It should be borne in  mind that in
all cases of ruptures,  so called, of the va-
rious ligaments in the experiments of Du-
puytren and Rognetta, these bands were
torn from their attachments to the bones,
and were not divided through the fibres
themselves.
   The articulations about the ankle may
be injured in various  ways,  by direct
forces, unattended with falls from a height
or errors  of position  in  walking—also
by the simple force of the muscles, in
dancing and other feats of agility.   The
latter causes of accidents  are most liable
to produce mischief in the practised vota-
ries of Terpsichore, whose joints acquire,
by habit  an extent of mobility inconsist-
ent with strength and safety; but nearly
every injury of the ankle may be reduced
to one or the other classes of accidents al-
ready described, and their mechanism has
been sufficiently developed.
   Art. III. Sprains of the Ankle. These
occur more frequently than similar  inju-
ries of any other joint and  the  mischief
that results is often  very severe.  In ad-
dition to the distension and partial rupture
of the articular ligaments,  there  are other
causes of evil,  not  so immediately  con-
nected with the joints. At the moment of
the accident some, or all,  of the muscles
of the foot are  called into spasmodic ac-
tion.   The strongest of these are connect-
ed with long and powerful tendons, which
are bound down, in the  neighbourhood of
the  joints, by their  theca?  and  what is
termed the annular  ligament, which are
 intimately  connected with the  fascia of
the  leg, and  are strongly attached,  late-
 rally, to the two malleoli.  (See  Blandin.
 Traite <TAnat. Topograph,  p. 649.)  The
 violent action of the muscles frequently
 occasions a disruption of some part of this
 apparatus,  and  of  the numerous small
 blood-vessels  that pass  between the apo-
neurotic fibres; hence,  severe injury to
the soft parts, and extensive ecchymoses.
  The  first symptoms of a  sprain are a
severe pain in the injured  part, with an
inability to exercise the proper functions
of the joint; the suffering being most in-
tense when the foot  is carried in the di-
rection in  which  it  was originally dis-
placed.  The  irritation  of the  accident
soon produces a great flux of the fluids to-
ward the seat of injury.  If the aponeu-
rosis or any of its processes are ruptured,
blood is effused into  the cellular tissue,
and the vital activity of the neighbouring
parts being increased, inflammation super-
venes, to a greater  or  less extent  In
slight cases, these symptoms subside in a
few days, without any unpleasant conse-
quences ; but in those of greater severity,
particularly if any ligaments are violently
twisted or torn from their attachments, ac-
tive treatment is frequently required; and
hydrops articuli,  enlargements  of the
neighbouring bursa? mucosa?, false anchy-
losis,  or,  in  scrofulous  patients, white
swelling,  may be  induced, in the face of
all precautions.
  Sprains  from adduction  are the  most
frequent and generally occur from habit-
ual carelessness  in walking.  The  mis-
chief,  in these cases,  is always extended
to the articulations between the astraga-
lus and the other bones of the tarsus; for
the fibula  is only broken by the  traction
of the lateral ligaments  in this motion of
the foot and these act at so great a me-
chanical disadvantage, that the bone  effec-
tually  resists  very  considerable forces.
The  short, strong, and oblique, internal
malleolus, also, opposes a great obstacle to
the lateral motion of the astragalus.   The
ankle joint thus guarded, the tarsal joints
are subjected to violent torsion before the
former articulation is seriously  involved.
The interosseous ligament suffers most in
severe cases,  and is  the ordinary seat of
the white swelling of the ankle.
   Sprains  from  abduction   are  less fre-
quent  for several reasons;  first, because
when one foot is turned upon  its  inner
edge, the other is, generally, immediately
employed  in supporting the body; which
at once arrests the abduction; secondly,
because the extent of natural motion in
this direction is  less  considerable, and
therefore better guarded, according to the
general law of all articulations, that the
greater the extent of motion, the greater
is the  facility of  injury; and thirdly, be-
cause the weakness  of* the fibula, which
is subjected to direct pressure in this ac-
cident, permits it to yield  to forces  com- 
ANKLE.  (Diastasis.)                           11
paratively slight, so that severe injuries
of this character are more likely to pro-
duce fracture of that bone, and luxation of
the foot  than simple  contortion of  the
joints. For the latter reason, also, the in-
terosseous ligament of the os calcis and
astragalus is less likely to suffer in violent
abductions, than where the foot is moved
in the opposite direction. The chief injury
is seated about the inner  malleolus, and
the deltoid, or internal lateral ligament,
is sometimes  torn  from its connexions.
The  experiments of M. Dupuytren  ap-
pear to prove that this ligament is always
separated from its attachments before the
fibula is fractured by abductions; but we are
inclined to doubt the  absolute certainty
of experiments performed upon the dead
body, nor can we conceive how this broad
band of fibres can be  entirely detached,
without  such a change in the position of
the  astragalus as must produce fracture
of the fibula,  under the ordinary circum-
stances attending the accident in the liv-
ing subject.  That portion of the ligament
which is attached  to the os calcis passes
over two articulations ; it must therefore
undergo  a  greater degree  of extension,
and may probably yield, before the  frac-
ture  of the bone takes place.
   Sprains from extension  of the foot are
serious,  because,  when severe,  they are
attended with a detachment of the ante-
 rior ligament  of the ankle joint, and rup-
 ture of the synovial membrane, as well as
 a distension of the interosseous ligament;
 they therefore partake  of some  of the
 characters of a partial dislocation compli-
 cated with a sprain of at least two impor-
 tant articulations.  It is  probable,  how-
 ever, that the injury to the last-named li-
 gament is seldom very important until the
 fibula is ruptured and the character of the
 accident changed.
   Treatment.  The immediate application
 of cold, in these, as in other sprains, is the
 most powerful of all measures for reliev-
 ing the ill effects of the injury.  For this
 purpose, the foot may be immersed in cold
 spring or ice water; or, what is still better,
 a stream of cold water, from a pump, hy-
 drant, kettle,  or any suitable vessel, may
 be allowed to fall from a height, upon the
 injured part.  The last method is interdict-
 ed in cases of severe superficial injury, for
 the force of the water may prove injuri-
 ous.   On the  first application of cold, the
 pain is  almost always increased in se-
 verity;  but, after  a time,  the  sensibility
t»f the part is diminished, and the foot be-
 comes completely benumbed.  The appli-
 cation should never be arrested until this
last effect is produced ; otherwise, the re-
action which  immediately  follows,  in-
creases the  swelling  and inflammation.
Respect  should be paid  to  the general
health of the patient,  in  prescribing this
remedy,  as, in catarrhal and consumptive
cases, &c, it may be inadmissible.  The
effect of the cold is greater, the earlier it
is employed; and in very severe sprains,
after the  swelling and inflammation have
supervened, it may exacerbate the symp-
toms, by  diminishing too much the vital
energy of the lacerated  and  debilitated
parts. Inflammation, if considerable, is  to
be  combated  by free  leeching, lead-wa-
ter, &c.;  and emollient applications, such
as poultices, and even warm ablutions, are
often very  serviceable.   When  the  in-
flammation has subsided, the energy of the
part may be sustained, and the absorption
of the ecchymoses facilitated, by resolv-
ent  and gently stimulating embrocations,
among the best of which is brandy, pure
or diluted.  Much benefit sometimes  re-
sults from the pressure of a roller well ap-
plied, in the decline of the case.   When
chronic  inflammation of the  ligaments
continues long, and  threatens  to produce
serious evil, blisters and other counter  ir-
ritants are applied  externally; but it is
highly important to remember that the di-
rect  irritation of these remedies  may in-
crease  the  evil, if they ere placed imme-
diately over the injured parts, when these
are superficial.   Hence, in sprains of the
ankle proper, they should not surround the
malleoli,  nor the front of the articular pul-
ley ; and when the  interosseous ligament
 is the seat of disease, they should not co-
ver  the  rear  of  the  internal  malleolus.
Throughout the whole treatment atten-
tion  to the motions of the foot, and its po-
sition, is indispensable.   Until all inflam-
matory symptoms have  ceased, absolute
rest  should be enjoined, and especial mea-
sures should be taken to prevent any re-
newal of motion in  the direction that ori-
ginally  produced the injury.  The foot
should be placed and retained in an ele-
vated position.   Partial or complete an-
chylosis,  hydrops articuli, ganglia,  rup-
tures of tendons, white swelling, &c., are
among the immediate or remote conse-
quences of sprains of the ankle: they will
be discussed in the appropriate general ar-
ticles.
   Art. IV.  Diastasis of the Inferior
Tibio-Fibular Articulation. This sepa-
ration of the  bones of the leg  may  be
either partial or complete; the latter va-
riety, however, is extremely rare.  Partial
diastases are never detected positively,  as 
12                          ANKLE.  (Fractures.)
they are always  complicated with sprains
and luxations with or without fracture of
one or both bones of the leg, the symp-
toms of which mask these accidents. They
require no modification of the treatment
adapted to the accidents which produce
them.  Complete diastasis is mentioned by
many surgical writers, as one of the pos-
sible  consequences of sprains and luxa-
tions of the ankle : it is exceedingly rare,
because the fibula breaks, in almost every
case,  before the  ligaments of this  articu-
lation yield; and in falls from  a height,
the direct upward pressure of the pulley
of the astragalus, combined with its late-
ral pressure on the  external malleolus,
and the consequent traction  of the liga-
ments, sometimes force  off a portion of
the outer part of the lower extremity of
the tibia,  so as  to leave the tibio-fibular
articulation  entire.  M.  Boyer  narrates
one very singular case, in which a luxa-
tion of the  foot by adduction forced  the
whole fibula from  both  its articulations
with the tibia, and drove it perpendicularly
upward.   By replacing the foot in its na-
tural position, the fibula was, in this case,
readily returned to its place.  Diastasis of
the lower articulation occurred once in
the course of fifteen years, at  the Hotel
Dieu, under Dupuytren.   It was accom-
panied by consecutive fracture of the fibu-
la, and what was termed by that surgeon,
dislocation of the foot outward and up-
ward.  Two hundred cases of other frac-
tures about the ankle, occurred during the
same period.  Sir A. Cooper does not no-
tice any case of the kind.  My attention
was called, some years ago, to a case in
the Pennsylvania Hospital, by Dr. Caspar
Morris, of this  city.  The patient had re-
ceived a very severe  sprain of the ankle
joint, attended with symptoms  indicating
a simple diastasis of the bones  of the leg
unattended by any fracture.  There exist-
ed a slight  tendency to  abduction of the
foot whenever the muscles  were called
into action,  and the distance between the
malleoli   was  then  sensibly  increased.
When moved by the hand of the surgeon,
the foot was found possessed of unusual
freedom of motion, in lateral rotation of
the toes  and abduction, which motions
greatly increased  the  separation of the
malleoli, and permitted a slight sub-luxa-
 tion of the foot  The cause most likely to
 produce this accident is, obviously, a vio-
 lent abduction of the foot accompanied by
 a direct lateral pressure of the leg inward.
   The treatment is very simple: a roller
 commencing at the  toes, neatly  applied
 about the heel and firmly surrounding the
malleoli so as to keep them properly ap-
proximated, at once  secures the patient
against any lateral derangement of the
foot.  By placing the  limb in the common
fracture box (see Leg, Fractures of) and
preserving the correct relation  between
the ball of the great  toe and the patella,
the tendency to evertion of the toe is also
corrected. Such was the mechanical treat-
ment in the case described, and it was
completely successful.  The firmness and
correct position of the external condyle
are so highly important to the exercise of
the proper functions of the foot that much
time  should be allowed for the  recovery
of  the ligaments before the patient  is
permitted  to  use  any violent  exertion
with the foot   Passive motions, avoiding
those  of abduction,  should be  employed
pretty early in all severe injuries of this
articulation, when  not complicated  with
external wounds.
   Art. V.  Fractures  about the An-
kle.   These are so various in their char-
acter and consequences, that it is difficult
to classify them.  They are caused either
by direct forces, such  as heavy blows,  or
the passage of great weights over this re-
gion, by violent extension  of the natural
motions of the foot, or the direct effect  of
the momentum of the body in falls.   The
fibula yields more frequently than the  ti-
bia, and the internal malleolus  is some-
times torn off with or without the rupture
of the fibula.   As these cases are almost
always complicated  with  primary or se-
condary sub-luxation  of the foot, they will
be noticed in the next article.  The same
may be said of that species of simple frac-
ture which detaches the outer part of the
inferior end of the tibia by the traction  of
the ligaments of the  tibio-fibular articula-
tion,—an  accident  always followed  by
fracture of the fibula also.
   In falls attended by abduction, the as-
tragalus is sometimes split though this
can scarcely occur except  in  compound
dislocations.  (See Astragalus.) There re-
main  two other forms of fracture  about
the ankle, which require especial notice
here.
   § 1. Simple Fracture of both bones  of
the leg very near the ankle joint. In this
case,  if the fracture  is produced by  a fall,
the fibula is almost always broken higher
up than the tibia,  and in the latter bone
the obliquity of the  fissure is  constantly
from without, downward, and inward  to-
 ward the malleolus internus.   The reason
 of this is obvious from the fact that in such
 falls  there is always a tendency to abduc-
 tion  of the lower fragment, both from the 
ANKLE.   (Fractures.)
13
 arched form of the inner side of the tar-
 sus, and  from the  mechanical advantages
 possessed by the abductor muscles,  as al-
 ready described in a preceding section.
   The nature of the consequent displace-
 ment  may be deduced from  these data.
 The superior fragment descends more or
 less, and the limb is shortened in a corre-
 sponding degree.   The  mutual relations
 of all the parts concerned  in the  ankle
 joint  are preserved; but the  whole foot
 together with the  inferior  fragments, be-
 ing drawn or driven somewhat outward,
 an inward angular deformity is produced,
 which is generally greater  as the seat  of
 fracture is approximated to the joint. Both
 these  species of displacement cause  the
 lower and outer part of the superior frag-
 ment  to  ride over and  conceal, more or
 less, the internal malleolus, and to become
 prominent on the  inside of the  joint be-
 neath the integuments, so as to simulate a
 sub-luxation with abduction of the foot.
   The diagnosis of this accident is by no
 means difficult.  The depression on  the
 outside of the leg, produced by the angu-
 lar derangement of the fragments, instead
 of commencing at  the external malleolus,
 as in  the corresponding luxation,  is lo-
 cated considerably higher, unless, as some-
 times  happens, the fibula  is broken  in
 more than one place.  The shortening of
 the limb,  when appreciable, is a clearly
 distinctive character; and any attempt to
 restore  the  foot to its proper position is
 productive  of a deep-seated crepitus, be-
 tween the tibial fragments.
   The principal difficulty  in the  treat-
 ment  of this species of fracture  results
 from the constant  tendency to a renewal
 of the displacement both in the longitudi-
 nal and lateral direction.  It not unfre-
 quently happens, however,  that the frac-
 ture of the tibia has an obliquity so slight
 that the limb preserves  its  proper length
 after coaptation; and the case is then very
 simple,  requiring  nothing  more than  a
 common  fracture-box for the limb  (see
 Leg, Fractures%f), with such an arrange-
 ment of the pillow, and, if necessary, com-
 presses, as will effectually prevent lateral
 derangement and preserve  the foot in its
 proper position.  But when the  inferior
 fragment is  constantly drawn  up by the
 muscles,  it becomes necessary to check
 this tendency, either by the total relaxa-
 tion of the great muscles, which may suf-
 fice in most cases, or by permanent ex-
 tension and counter extension.  All that
 is necessary to fulfil the first of these in-
dications  is to elevate the fracture-box,
still preserving its  horizontal position, so
   VOL. II.          2
 that the leg is flexed on the thigh and the
 thigh on the pelvis.  Where permanent
 extension is required, the straight position
 of the whole limb, and Dr. Physick's mo-
 dification of Dessault's splints, are almost
 universally employed in this country. (See
 Thigh, Fractures of.)  The  attempt to
 make counter-extension from the knee is
 inadmissible, as the bands  used for that
 purpose embarrass the circulation.   The
 extending bands should be so arranged as
 to act upon the heel and  instep without
 covering the malleoli. Sir A. Cooper em-
 ploys lateral carved splints with foot-pieces,
 in all fractures about the ankle; but the
 difficulty of adapting these exactly to each
 particular case  is  a strong objection to
 their  use. (TV. on Fractures  and Dislo-
 cations, p. 332.)  For all details on the
 general treatment and apparatus, the read-
 er is referred to the articles on Fractures,
 and Leg.
   J 2.  Fractures of the Tibia communi-
 cating with the ankle joint.  These acci-
 dents result from considerable falls, and
 are various  in character; sometimes the
 outer side of the  lower extremity of the
 bone is driven off, continuing its connexion
 with the fibula; and if the fracturing force
 is expended in  producing this  mischief,
 the case resembles a diastasis of the tibio-
 fibular articulation, and requires the same
 treatment.   It is distinguished from that
 accident by the  crepitus produced by ro-
 tating-the foot   If the force is continued,
 the tibia slides  oft* from the articular pul-
 ley and descends internally, while the as-
 tragalus ascends between the bones of the
 leg, or  rather between the  fragments of
 the tibia, constituting what Sir A. Cooper
 terms Dislocation of the foot upward. (Op.
 Cit. p. 333.)  If the articular surface of
 the tibia is  comminuted in  this accident,
^there may be a  tendency to constant re-
 traction of the foot, and more or less per-
 manent deformity is generally the result.
 The obliquity of these fractures is  often
 the reverse of that just mentioned.   It
 passes from the joint upward and inward,
 producing a separation of  the internal
 malleolus from the body of the bone. There
 id then  a tendency to adduction of the
 foot, but its  luxation is prevented by the
 integrity of the fibula and external lateral
 ligaments.
   The treatment of these varieties of frac-
 ture should be regulated on the same prin-
 ciples, and requires the same  apparatus,
 as the accident last described.
   } 3.  Fractures of the  Fibula near the     ?
 ankle joint.   In nearly every case of pri-     «i
 mary dislocation or sub-luxation of the an- 
J4                          ANKLE.
(Fraciurts.)
kle, the fibula becomes broken consenta-
neously, within a few inches of the joint.
The causes, effects and treatment of these
accidents,  form the subject of the suc-
ceeding article,  and we shall therefore
confine ourselves in this place to the con-
sideration of such  fractures  of the fibula
as are occasioned by direct forces, and in
which malpositions of the foot appear con-
secutively.
   When any solution of continuity takes
place in the fibula, between its two arti-
culations,  its  fractured extremities  are
drawn towards the tibia by the fibres of
several muscles which take their origin
from the former bone.  This angular de-
formity gives to both fragments an unna-
tural obliquity, which is of little conse-
quence in the upper fragment but is high-
ly important in the lower; for the latter
turns upon the inferior tibio-fibular articu-
lation, as on a pivot; and as the superior
extremity of this fragment  tends toward
the tibia, the malleolus externus is neces-
sarily carried outward;  the cavity which
receives the head of the astragalus is thus
widened, and the natural counter-check to
the abduction of the  foot is lost.  If the
fracture occurs within three inches of the
ankle joint, the  obliquity of the lower
fragment is so great that a slight sub-lux-
ation of the foot takes place  merely from
the contraction of the abductor muscles,
and when reduced, the displacement con-
tinually reappears  the moment that  the
foot  is deprived  of mechanical support.
Even if the foot  is maintained in its na-
tural situation,  the  laxity of the peroneo-
tarsal ligament permits  the  angular  de-
formity to remain,  and if the fragments
are allowed to unite in this their malposi-
tion, the foot remains permanently subject
to a degree of abduction incompatible with
the proper exercise of its functions. The
projection of the external malleolus  be-
yond the end  of the tibia is so short that
it is extremely difficult to act upon it di-
rectly  by means  of any  apparatus which
will not at the same time press upon the
portion of the  fibula above the joint, and
thus neutralize its own usefulness.  The
only sure mode of correcting the tenden-
cy to displacement is to act on the  malle-
olus through the peroneo-tarsal ligaments,
for when the  foot  is strongly adducted,
these ligaments are put  upon the  stretch
and compel the malleolus to return to its
proper position, while  the interosseous li-
gament of the  leg prevents  this motion
from being carried so far  as to produce an
angular deformity in the opposite direc-
tion.
   In order to maintain the foot in a state
 of adduction  during the  cure,  the older
 surgeons employed a splint reaching from
 the knee to  some distance below the foot
 on the outside of the leg, covered by cu-
 neiform compresses with the base of the
 wedge downward, so as to extend quite to
 the  sole of the foot;  and a second splint
 on the inside of the  leg, terminating at
 the  inner ankle.   The limb being enve-
 loped in bandages as usual, and the splints
 applied, and  secured  by suitable means,
 the pressure of the thick extremity of the
 external compresses was designed to press
 the foot and the malleolus inward.  The
 results of this treatment were  avowedly
 unsatisfactory. (See Art. VI.  5 1.)
   It remained for M. Dupuytren to insti-
 tute a more  philosophical  plan of treat-
 ment.  The apparatus of this surgeon con-
 sists of, firstly,  a cushion of linen  about
 two-thirds filled with cotton,  four or five
 inches broad,  three or  four thick, and long
 enough when doubled  on  itself to extend
 from the knee to the  ankle; secondly, a
 firm splint from eighteen to twenty inches
 long, two and a  half inches broad, and
 three or four lines thick; and lastly, two
 rollers, each  four or five ells long.
   The  cushion when doubled upon itself
 lengthwise forms a kind of wedge.  It is
 applied upon the inside of the leg, its thin-
 ner  end corresponding with the condyle
 of the femur, and its thick  doubled ex-
 tremity extending to the  internal malleo-
 lus, but not beyond it   Over this cushion
 the splint is secured with one end oppo-
 site the knee and the other extending five
 or six inches beyond the cushion, and two
 or three inches below the foot The splint
 being fixed  by one of the rollers passed
 round the leg and the  apparatus near the
 knee,  the other  is carried by figure-of-
 eight turns round the projecting extremity
of the  splint  and  the  foot so as  to em-
brace alternately the heel and the instep.
The malleolus internus supported by the
cushion is thus used as a fulcrum, and the
foot being drawn and heW in a state  of
adduction, over the end of the cushion, by
the figure-of-eight bandage, the peroneo-
tarsal ligaments are put  on the stretch,
and the malleolus is drawn inward With-
out any counteracting force being applied
to the  upper part of the lower fragment
of the  tibia.  (Annuaire Medicate, 1819.)
  For many other particulars with regard
to fractures of the fibula, complicated with
displacements of the foot, and for our re-
marks on the applicability of the appara-
tus just described, in such cases, the read-
er is referred to the succeeding article on 
ANKLE.   (Dislocations.)
15
Dislocations of the Ankle: we will there-
fore close the present section with the re-
mark, that when the fracture occurs im-
mediately above the  lower  tibio-fibular ar-
ticulation, the inferior fragment is not dis-
placed by muscular contraction, and hence
it is not only unnecessary, but injurious to
retain the foot in a state of strong adduc-
tion in such cases; for the traction of the
peroneo-tarsal ligaments may then cause
the fragment to follow the motions of the
foot as far as  the elasticity of the  pero-
neo-tibial ligaments  permits, and thus a
slight  degree of deformity be produced,
which may limit  the proper freedom of
abduction  and  circumduction after the
union  of the fracture is complete.  This
result  we once witnessed.   It  is  suffi-
cient in such cases for the foot to be pre-
served  in a perfectly  relaxed  position,
which is easfly effected by the same ap-
paratus,  care being taken to employ a
cushion a good deal  narrower at the sum-
mit  of the wedge,  than that  above de-
scribed.
   Art. VI.  Dislocations of the  An-
kle.   The occurrence of a dislocation of
the  ankle free from complication with
fracture is an  exceedingly rare  occur-
rence, if indeed it ever happens.  The ad-
duction of the foot would doubtless produce
this accident frequently, were it not for the
fact that the external lateral ligaments
exceed in strength  the fibula from which
they arise; the tibia might indeed  pass
forward upon  the dorsum of the  tarsus,
and  if there should exist at the same time
a diastasis of the tibio-fibular articulation.
the fibula might escape fracture.  The pos-
sibility of this  accident  has been noticed
by several surgical  writers,  but  we have
met with no detailed case.  It may be re-
marked with equal propriety that the dis-
locations of the ankle are never complete,
except perhaps in one variety, for in no
other  case does the astragalus  entirely
quit the corresponding articular  surfaces.
The terminology  of these accidents is in
great  confusion; by some surgeons they
are described under  the name of  luxations
of the astragalus (B. Bell. Syst. of Sur-
gery,  t 7."), and are thus confused with
other accidents of a very different nature.
Many modern  surgeons term them luxa-
tions of the foot;  but they speak of luxa-
tions of the foot  outward or inward, ac-
cordingly as the  foot is abducted  or ad-
ducted.  (See S. Cooper.  Surg. Diet. p.
402. Ed. 5.) Most of the French modern
writers use the same terms, but in a sense
precisely the reverse of that just  mention-
ed.  (See Boyer.  Mai. Chir. t  IV., and
Dupuytren.  Annuaire Medicale, 1819.)
They call a case of luxation with abduc-
tion of the foot a dislocation of the foot in-
ward, and vice versa, because the pulley
of the astragalus is directed inward, when
the foot is carried outward, and outward,
when the foot is carried inward !  In the
attempt to prevent confusion from this di-
versity, Sir A. Cooper has increased the
difficulty, by naming the different luxa-
tions of the foot according to the direction
in which the lower extremity of the tibia
is carried by the  accident. (See his Sur-
gical Essays, and Treatise on Fractures
and Dislocations.) Thus he terms the dis-
location with abduction of the foot, " Dis-
location of the tibia  inward at  the ankle
joint," and describes the others in a simi-
lar manner. I need hardly apologize then
for the introduction  of  terms which it  is
hoped will prevent all misconception, par-
ticularly as the synonyms will be append-
ed.  The  elucidation of the modus ope-
randi of the motions of the foot  in pro-
ducing luxations, when carried beyond the
proper extent, as  given  in a former arti-
cle,  render it unnecessary to dwell upon
that subject here, and our remarks will be
very short.
   5 1. Sub-luxation of the ankle with ab-
duction of the foot.  This  is the disloca-
tion of the foot outwards,  of  many sur-
geons ; the dislocation inwards, of Boyer
and Dupuytren;  and the dislocation of
the tibia  inward from the astragalus, of J
Sir A. Cooper.   The mechanism'of its
production, and the cause of its greater
frequency, when  compared with other
injuries of the same class  affecting this
joint,  have been explained in the first
pages  of this  article.   The  relative
changes among  the parts of  the arti-
culation in this  luxation are as follows.
The  deltoid ligament  is  torn,  in part
or  entirely,  from   its  connexions with
the tibia, or, if this does not happen, the
internal malleolus is  fractured and detach-
ed by the traction of the ligament.  The
fibula  is  fractured above its articulation
with  the  tibia, at  some point within two
and a half inches of that spot.   The pul-
ley of the astragalus inclines inward, and
the lower extremity  of the tibia slides off
from its superior face, and descends more
or less upon its inner side,  so as to occa-
sion a great prominence on the  inside of
the joint  and  a  corresponding depression
externally.  The external malleolus re-
tains  its natural relations with the astra-
galus, following it in its displacement,  so
that the inferior fragment of the fibula in-
clines toward the tibia.  That part of the 
16                         ANKLE.  (Dislocations.)
latter bone which gives attachment to the
ligaments from the fibula is torn off from
the shaft and  follows the motions of the
external malleolus.   The  superior  frag-
ment of the fibula, drawn  inward by the
interosseous ligament of the leg, follows
the tibia and descends so  as to approach
the middle of the pulley of the astragalus,
thus taking the  place of  the  bone just
mentioned, to use the language of" Sir A.
Cooper.  The foot  rests upon its inner
edge, and  the plantar surface  is directed
outward.  If the foot has been suffered to
remain in its false position until the  mus-
cles have contracted, considerable difficul-
ty is  experienced in any attempt at ad-
duction ; but abduction may be  carried to
such an extent as to  cause the sole of the
foot to present outward and upward.  This
complete overturning of the  foot some-
times takes place in consequence  of the
continuance  of  the  original  fracturing
force: it would occur more  frequently but
for the facility with which the other foot
is made to arrest the descent of the body.
In such cases the fibula is usually broken
in more than one place, and the end of the
tibia approaches the sod, commonly pene-
trating the  integuments, so  as to compli-
cate the luxation with an external wound.
  A dispute exists among surgeons as to
the  cause of the fracture of the fibula in
this accident which, as it has been made
the  foundation of certain practical injunc-
tions, demands a passing notice.  M. Pou-
teau asserted that it might be broken by
the  simple force of the muscles in making
a false step.  Most writers, among whom
we  may especially notice David and Boy-
er,  consider the  direct pressure on the
malleolus, with the resistance of the tibio-
fibular articulations, combined with  the
action of the peronei  muscles, as the cause
of the fracture, which they consider as the
result of a  kind of contre-coup.  Dupuy-
tren  strongly opposes this  doctrine, be-
cause on the dead subject he was  able to
produce luxation before the fracture  took
place, and he  is  therefore led to consider
the  latter as a consecutive  accident; he
moreover observes that in luxations by ad-
duction, the fibula is broken by traction.
  It appears obvious to us that the frac-
ture may occur from either or any of these
causes.   That mentioned by Pouteau is
perhaps the most questionable; but the
whole mechanism of the joint goes to show
the impossibility of a dislocation outward,
from any of the forces that ordinarily pro-
duce it, without a contemporaneous frac-
ture of the  fibula, even supposing the del-
toid ligament to have been previously torn
from  its connexions.  We have  already
mentioned in the preceding  article, that
this disruption sometimes  occurs  without
luxation, and the experiments of  Dupuy-
tren performed  upon the dead  subject
where the weight or the  momentum of
the body is not taken into account, furnish
an argument to the contrary, of less force
than might be at first supposed. The fibula
is often  primarily broken  by direct force,
and the foot consecutively luxated; a case
at war with the exclusive positions of all
the surgeons  above  mentioned.  At last,
this discussion   derives  its  importance
chiefly from the great names of the oppo-
nents.   All that it is important to  remem-
ber, in a practical point of view, is the fact
that the fibula is always broken except in
the unique case of its double diastasis (see
Art. IV.), and that the peroneo-tarsal liga-
ments retain their connexions.
  The  indications  for  the treatment of
this accident  are, 1st the speedy reduc-
tion of the foot to its natural position; 2d,
the prevention of a recurrence of  the dis-
placement  by muscular action;  3d, the
correction of the tendency  of the superior
end of the inferior fragment of the fibula
to approach the tibia, which if unchecked
would cause the external malleolus to turn
obliquely outward so as  to render the as-
tragalus  unsteady in its socket; 4th, the
arrest of the inflammatory symptoms; and
5th, the prevention of consequent stiffness
in the joint.
  The first indication is  easily fulfilled if
the accident  is of recent occurrence, but
if several days have been suffered to elapse
much difficulty may be experienced.  To
effect the reduction in the easiest manner,
the surgeon flexes the thigh on the pelvis,
and the leg on the thigh; he then directs
one assistant to interlock his hands behind
the limb just above the ham, and another
to grasp the front of the leg just above the
site of the fracture in the fibula. He then
seizes with one hand the projection of the
heel, and with the other, the inner edge
of the  foot, the  fingers passing over the
instep, and the thumb resting beneath the
sole.  He then  directs  the toes  a little
downward, in order  to relax the muscles
as much as possible, and making steady
extension, at first  a little outward and
then more directly downward, he causes
the foot to reverse  the motion which oc-
casioned the luxation.  We have never
seen a case in which the  muscular con-
tractions resisted these simple efforts at
reduction, before the reunion of the fibula
had rendered all such attempts improper;
but as  such instances are said sometimes 
ANKLE.  (Dislocations.)                         17
to occur, it may be remarked that the silk
handkerchief, applied as directed for ex-
tension in fractures of the lower extremi-
ties  complicated  with  injury  about the
malleolus, wdl furnish the best means of
increasing the extending force.  (See Leg,
Fractures of.)  With regard to the second
indication it should be observed that the ar-
ticular  surface of the tibia effectually op-
poses all displacement so long as the foot
is kept  in its natural position by mechanic-
al means; but  these measures are insuffi-
cient for the fulfilment of the  third indi-
cation; for the displacement of the inferior
tibial fragment does not depend solely on
the  malposition of the foot but also upon
the  action of the  peronei muscles.  This
constitutes the  chief difficulty in the treat-
ment of nearly all the dislocations of the
foot; and it is to Dupuytren that we owe
the  first correct description  of the most
rational means for  combating  the evil.
Mr.  Pott, led astray by his favourite the-
ory of relaxation  in fractures, and attri-
buting the lateral  displacement of the ex-
ternal malleolus mainly to the pressure of
the astragalus upon it under the action of
the abductor muscles, contented himself
with placing the  patient on the injured
side, with the thigh and leg  in demi-flex-
ion, and the outside  of the foot resting on
the bed.  Mr. Bromfield, who displays a
better  knowledge of  the indications in
these accidents, attempted to act directly
upon the malleolus by means of graduated
and  stiffened compresses and a figure-of-
eight bandage.  (Surg.  Obs. and  Cases.
II. 77.)  Most  English surgeons have fol-
lowed up the  ideas of these authorities.
The application of graduated compresses
and  the flexed position are retained, and
the  limb continues to be enveloped in a
many-tailed  or Scultet's bandage; but
lateral splints are  added to the apparatus
to render its action more steady.   Sir A.
Cooper (Loc. Cit.) uses his  splints with
carved foot-pieces. The French prefer the
extended position,  but all those who pre-
ceded Dupuytren seem to have acted in
other respects  upon the same principle.
Boyer  employed  two plain  splints,  one
for the outside of the leg, extending from
the knee to  some distance below the foot;
the other, internal and terminating at the
inner malleolus.   These, lined  by chaff-
bags, were  applied  over the  graduated
compresses  and roller,  the long  splint
pressing the foot inward.  (Mai. Chir. IV.
384 and 386.) There can be no important
advantage gained by the flexed position in
these accidents, for the slightest examina-
tion of the joint will show that the reduc-
                  2*
tion once  accomplished and the foot se-
cured against abduction, the  extension of
the muscles of the leg tends rather to se-
cure the astragalus in  its proper position
than to cause  displacement; but there are
very strong objections against the modes
of dressing above described.  Graduated
compresses secured by roller or the many-
tailed bandage produce  considerable pres-
sure on the whole  length  of the fibula.
Now the slight projection of the malleolus
causes the pressure on this part  to act at
a very slight mechanical advantage, while
the length of the lower fragment of the
fibula is usually so considerable that pres-
sure upon its upper end acts with at least
three-fold force, as may be  proved by ac-
tual admeasurement and the application
of the  law of  the lever.  Dupuytren em-
ploys the external lateral ligaments them-
selves  to  counteract the muscles, in the
manner described in the section on frac-
tures of the fibula. (Art. V.  § 3.) By the
employment  of his apparatus,  the late-
ral ligaments draw inward the external
malleolus with  any  required degree  of
power,  and no pressure need be applied
to the upper end of the fibular fragment
(Annuaire Medicate. 1819.) Care should
be  taken  not to carry  the  adduction too
far, or the astragalus will display a ten-
dency  to overturn in the opposite direc-
tion, in which case,  if the internal malle-
olus is broken, it will be displaced, and if
it retains its integrity, it compels the outer
edge of the pulley to react on the exter-
nal malleolus so as to lessen the  effect of
the traction of the ligaments by shortening
the arm of the lever on  which they act
   This mode  of treatment is equally ap-
plicable to many of the other luxations of
the foot,  as  they are almost invariably
complicated with  fracture of the  fibula,
which  at  once becomes  one of the most
important features in the case.
   The  fourth and fifth  indications need
not be  dwelt upon in this place, as they
are common  to  these and all other frac-
tures complicated with  sprains and luxa-
tions, and will be considered under the ap-
propriate general heads.
  \ 2.  Sub-luxation of the ankle, with ad-
duction of the foot.  This is the disloca-
tion of the foot outwards, of Dupuytren
and Boyer ; dislocation  inward, of most
surgeons; and the dislocation of the tibia
outward from the astragalus, of Sir A.
Cooper.
  This  accident is  much less frequent,
but proportionably more formidable, than
that described above.  The foot moves in
the opposite direction; the external mal- 
18                         ANKLE,  (uisiocuavns.)
 leolus is torn off by the lateral ligaments;
 the internal,  is either detached  by the
 pressure of the astragalus, or the inner
 side of the  extremity of the tibia is frac-
 tured obliquely in  a direction from the
 joint upward and inward ;  the remainder
 of this  bone starts outward  and  forward
 before the  external malleolus; and the
 fibula generally yields  in  several places.
 Even the astragalus may be split,  through
 the pulley;  this articular process is over-
 turned, so  that its  superior face presents
 obliquely outwards; the broken end of the
 tibia descends on its outer side; the exter-
 nal malleolus  becomes very prominent at
 the corresponding side of the joint and  is
 exceedingly apt to penetrate the integu-
 ments ; the inner side of the pulley pushes
 upward the inner fragment  of the tibia;
 the corresponding edge of the foot inclines
 upward, the  other edge  rests  on  the
 ground, and the plantar surface looks ob-
 liquely  inward.
   The  indications  in this, are nearly the
 same with those in  the former lateral lux-
 ation ; but we have also to guard against
 the tendency of the foot to be carried in-
 ward.   The reduction is accomplished in
" the same manner as in luxation by abduc-
 tion,  the  foot  being  carried in a nearly
 contrary direction; but if  great difficulty
 is experienced, the operator can use an
 extending band which may be given to  a
 third assistant, and by pressing with one
 hand on the  heel  and the other on the
 lower end of the tibia, he may then employ
 any warrantable degree of force.
    Surgeons have  generally  treated  this
 accident with the same  apparatus that
 they have severally employed in the.sub-
 luxation with abduction, reversing the or-
 der  of the compresses  so  as to make the
 greatest pressure upon, and below, the in-
 ternal malleolus, and to thrust the foot out-
 ward ; but it must be borne in mind that
 all the evils resulting from an ill-managed
 fracture of the fibula must  necessarily fol-
 low this process, for the external malleo-
 lus is driven outward by  such a plan of
 proceeding, and there is as little  security
 against displacement of the foot in that di-
 rection as in the other.
    Dupuytren employs the apparatus de-
 vised by himself for fractures of the fibu-
 la, placing the cushion  in  these cases on
 the outside of the leg,  and keeping the
 foot in a state of permanent abduction over
  its doubled  extremity.  The objection just
 stated  applies  with still greater  force
 against this mode  of treatment.
    The foot is rendered exceedingly un-
 steady by  this double  fracture  of both
bones of the leg,  and in some cases the
slightest change in its position enables the
muscles to renew the displacement.  For-
tunately, the fibula, when it yields to trac-
tion, is generally ruptured  immediately
above the articulation with the tibia: the
lower fragment is not then drawn inward
by muscular contraction, and no degree of
derangement among  the other fragments
of this bone  can materially injure the mo-
tions of this joint so long as the malleolus
retains its proper relations.
  The great object  then  is to keep the
foot in a perfectly relaxed position, i. e. to
retain the point of the great toe nearly on
a line with the patella, with the toes point-
ed somewhat downward, and the tarsus in
a state  of semi-adduction  on the astraga-
lus.  This is easily  accomplished by ad-
justing the  limb  in  a  common fracture-
box, or by  applying two  lateral  splints
from the knee to the  ankle, with well ar-
ranged chaff-bags, and bands  passed round
the toes and secured to the splints if ne-
cessary.
  The  carved  splints  of  Sir A. Cooper
are objectionable because  they cannot be
adjusted to particular cases without great
difficulty, are not easily  procured,  and
often  interfere unnecessarily  with local
applications to the ankle.
  This accident  is always attended with
sprain of the articulations between the as-
tragalus and tarsus,  which circumstance
should not be overlooked in the treatment.
  § 3.  Luxation  of  the foot backwards.
This dislocation may be either partial or
complete.  It is caused by violent exten-
sions of the foot  in  falls  and other acci-
dents, when the foot  is  suddenly arrested
while the momentum of the body contin-
ues. It may be caused  by  the heel catch-
ing on the edge of a step when descend-
ing a flight of stairs (see Dorsey's  Ele-
ments of Surgery);  but perhaps the most
frequent cause is  a fall from a height, on
an  inclined plane, when some accidental
irregularity of surface  prevents the  sub-
luxation from abduction.  The accident is
rare.   M. Bo\er declared, in 1814, that
but one case had ever fallen  under his ob-
servation.
  In the  partial  luxation, Sir A. Cooper
remarks that the tibia rests half on the as-
tragalus and half on the  os naviculare;
the fibula is broken;  the heel  is shorten-
ed ; and the distance from the malleoli to
the toes is proportionally increased.  The
latter  are pointed downward in  conse-
quence of the contraction of the great ex-
tensor muscles, and the  ankle joint is ren-
dered  nearly  immovable  with the  toes 
ANKLE.   (Dislocations.)
19
only resting on the soil.  It is distinguish-
ed from complete luxation by the slighter
extent of the deformity, and the accident
may be masked  by the swelling  which
soon supervenes.
  In the complete luxation, the tibia rests
almost entirely on the os scaphoides and
the  internal os  cuneiform, its posterior
edge merely touching the front part of the
pulley of the astragalus.   The toes point
strongly downward, resting on the ground.
The joint is immovable, and the front part
of the foot is so  much shortened that the
accident cannot be mistaken.  The fibula
is broken, and  its upper fragment  passes
forward with the tibia.   The  tibio-fibular
ligaments do not yield, and the external
malleolus remains in situ.
  Reduction is accomplished by placing
all the muscles interested,  in the greatest
possible  degree of relaxation, and effect-
ing extension,  either by the hands  of the
surgeon,  or by means of a handkerchief
applied in the manner to which we have
already alluded when speaking  of the la-
teral sub-luxations, the foot being carried
forward  at the same time, and gradually
flexed, as the  pulley returns to its place.
To aid in effecting the extension it is pro-
per for one assistant to support  the  thigh
near the ham with his  clasped  hands,
while a  second  embraces in  the  same
manner  the front of the  leg about four
inches above the ankle.  In this accident
the  deltoid ligament is  detached more or
less completely, the transverse posterior
ligament of the tibio-fibular articulation is
injured, the anterior ligament of the ankle
is lacerated, and  the front  part of the sy-
novial membrane torn.
   When reduced, the fracture of the fibu-
la leaves the joint liable to the consecu-
tive sub-luxation by abduction (q. v.), and
the  case  demands the  treatment adapted
to that species of injury; but as the trans-
verse posterior ligament is  weakened, it is
necessary to be more  particular in keep-
ing  the  foot well flexed upon the leg, in
order that the great extensor muscles may
act at right angles to the antero-posterior
axis of the joint  els© they would tend to
draw the foot backward and might repro-
duce the luxation.
   "> 4.  Luxation of the foot forwards.
This is  enumerated among the possible
accidents of the  ankle joint, and  some
writers go  so  far as to explain the me-
chanism  of  its production (see Boyer.
Mai. Ch. t. TV.), but its existence  is pro-
blematical.   Should it occur, the inferior
extremity of the tibia would be found rest-
ing on the back of the os  calcis with the
front edge overlapping the posterior mar-
gin of the astragalus, the projection of the
heel being almost destroyed, and the front
of the foot proportionally elongated.  The
method  of reduction  would consist  in
making as much  extension  as possible,
both by directly drawing the foot down-
ward, and by depressing the toes, so as to
use the whole foot like a lever whde it is
forcibly thrust backward.  When reduced,
this case would resemble the last,  in all
essential particulars.
  In all cases of luxation of the ankle, it
is highly important to  guard against the
stiffness of the joint consequent upon the
extensive alterations and adhesions of the
ligaments  and  tendinous theca?,  while
every precaution should be used to pre-
vent undue exertion until the tardy pro-
cess of reunion in  the  white tissues is
fully  established.    As  a general  rule,
passive  exercise may  be commenced in
four or five weeks,  according to the age
of the patient  it being held constantly in
mind that the natural motions of this ar-
ticulation are simply those of flexion and
extension—all others are injurious. In six
or eight weeks the patient may leave his
bed, but  he should be prohibited  from
using great  exertions for several months.
The complete union of the fractured bones
is no sufficient proof of the firmness of the
ligaments.
  5 5.  Compound luxations of the ankle.
These were  formerly considered as cases
always requiring amputation, but in latter
times so many grave accidents of this kind
have recovered without even the entire
loss of the movements of the joint, that it
has become customary to attempt the pre-
servation  of  the limb  under very despe-
rate circumstances.  We have seen  so
many patients  succumb under these at-
tempts, that  we  have  been  inclined to
think the  profession in danger of passing
from one extreme to the other. The ques-
tion of the propriety of amputation is often
one of great difficulty.   In patients of vi-
gorous constitution, surrounded with all
the conveniences of life, and provided with
the best surgical advice and suitable as-
sistance, the  knife  is very rarely required.
Even in such cases, however, the division
of both the tibial arteries, the very exten-
sive laceration of the soft parts, or the
comminution of a great extent of bone, is
considered a sufficient reason for removing
the injured parts.  On the contrary, when
such luxations occur on the field of battle,
in places where the supervision of expe-
rienced surgeons cannot be had, or where
the poverty of the patient deprives him of 
20                          ANKLE.   (Dislocations.)
 the necessary resources, amputation should
 be occasionally  perfonned in cases that
 would  in all probability recover under
 more favourable  auspices. Whenever any
 of the bones protrude in a dislocation  of
 the ankle happening to a very weakly pa-
 tient,  one  who  has  recently  recovered
 from severe and  debilitating disease, or in
 whom symptoms of pulmonary consump-
 tion have  made their appearance, the
 chances are very much against the reco-
 very.   Sir A. Cooper expresses his  sur-
 prise at the extreme infrequence of injury
 to the posterior tibial artery, the anterior
 tibial being the  only vessel that  he has
 seen injured (Tr. on Fractures and Dis-
 locations, p. 242.);  the arrest of the cir-
 culation in the foot must therefore be a
 very rare occurrence.
   We shall not  enter into the history of
 the constitutional symptoms which follow
 these accidents,  nor the treatment which
 they require.  These details, and the ques-
 tions of the propriety of removing isolated
 fragments, and of excising the projecting
 extremities of the bones when irreducible,
 &c., are more properly referred to the ge-
 neral article on Dislocations (q. v.), and it
 is only necessary  at present to notice a few
 points peculiar to luxations of the ankle.
   Nearly all the cases of compound dis-
 locations of this joint are the result of the
 lateral displacement of the foot.   When
 the accident is occasioned by abduction, it
 is generally the tibia only that penetrates
 the integuments, but when the foot is dis-
 located by adduction,  both bones appear,
 the  superior fragment of the fibula de-
 scending with  the tibia, and  penetrating
 the  integuments first.  In each variety,
 the projecting bones are very apt to reach
 or even to  enter the ground, and become
 covered with dirt and other foreign  sub-
 stances ; these impurities must be removed
 with the utmost care before the  bones are
 replaced,  or very terrible consequences to
 the joint  may follow.  The reduction  is
 accomplished  in  the  manner prescribed
 for similar  luxations  when simple,  the
 wound being enlarged if necessary to  free
the protruded bones from stricture.  Sir
A. Cooper directs as the first dressing to
the wound, a piece of lint dipped  in the
blood of the patient which he  considers
as the blandest and  most congenial appli-
cation that can be made.
  In some happy instances the wound ad-
 heres without  inflammation of the joint,
and  the case  is  converted  into  a simple
 luxation;  but if this process fails, suppu-
 ration of the cavity,  often followed by ex-
 foliation of the bones,  and anchylosis,  is
 the result.   Still, as the eminent surgeon
 just  quoted remarks, the  motion of the
 joint is not always lost.   If passive mo-
 tions are practised as early as possible, it
 is not unfrequently preserved in a  great
 degree, and even in worse  cases, the gra-
 dual extension of the natural motions of
 the tarsal  articulations  in  part  supplies
 the defect,  with time.  The time required
 for the recovery, after suppuration of the
 joint, is always very considerable: " Un-
 der the most favourable  circumstances,
 three  months generally elapse before the
 patient can walk with crutches; in many
 cases, however, a greater length of time
 is required." (Op. Cit. p. 245.)
   It is impossible to lay down any positive
 and general rules for the mechanical treat-
 ment of these accidents;  but one  point
 must be kept steadily in view; the foot
 must be carefully preserved at a right an-
 gle with the leg, in order that if the mo-
 tion of the joint  is lost it may be perma-
 nently fixed in the most favourable posi-
 tion.  In some cases the limb may be best
 supported in a fracture-box, in others it
 may  require one,  or  even two  lateral
 splints with graduated compresses; some-
 times it is best placed on the side,  and at
 others on the heel.  The general princi-
 ples laid down in speaking of the simple
 luxations should  guide us  whenever the
 character of the  case does not require
 some peculiar contrivance.  For further
 details, see  Art. Dislocation.
   Other accidents to the ankle,  in which
 the astragalus is  more  particularly  in-
 terested, will be  described in a separate
 article. (See Astragalus.)
   } 6. Dislocation  of the foot outward
 and upward.  A term applied to a  com-
 plicated  species of diastasis of the  infe-
 rior tibio-fibular articulation. (See Art. 4.)
   §7. Dislocation of the foot upward. A
 term applied by Sir A. Cooper to a  com-
 plicated  fracture of the tibia  communi-
 cating with the ankle joint  (See Art 5.
 5 2.)

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                    Reynell Coates.
   ANODYNES. (From a priv. and oSwr;,
pain.)   This name, as its origin indicates,
is applied to  medicines calculated to re-
lieve pain.   To  one who considers how
numerous are the causes of pain, and how
various are  the morbid conditions with
which it is associated, it must be obvious,
that the possession of a power to mitigate
or remove it cannot properly serve as the
basis of a class  in the  Materia Medica;
for, otherwise, substances would be thrown
together wholly different in their nature
and modes  of action; and, in  fact, the
whole catalogue of medicines  would be
compressed into a single class; as there
is scarcely  one which, under certain cir-
cumstances, may not be made,  either di-
rectly or indirectly, to produce an anodyne
effect   It would be futile, therefore, to
attempt to give,  under this head, a full ac-
count of the properties of anodynes, their
modes of operating on the system, the in-
dications for their use, and the rules which
should regulate their administration.  This
information must be sought for in the ob-
servations upon the  various recognized
classes of medicines,  and upon the medi-
cines themselves individually considered.
A few brief  remarks,  however,  may be
useful by serving to give precision to the
subject.
   Pain may be relieved in one of three
ways; first,  by removing  the exciting
cause of that irregular action of the nerves
on which it depends; secondly, by correct-
ing this irregular action through the agen-
cy of means  directly addressed  to  the
nervous system; and thirdly, by diminish-
ing sensibility through narcotic impres-
sions on  the brain.   Anodyne  remedies
may be arranged in divisions correspond-
ing with these several modes of action.
   1. The first division includes, first, all
such means as are calculated to  remove ox
neutralize extraneous sources of irritation,
as emetics and cathartics in colic from un-
digested food or acrid secretions, anthel-
mintics in verminose complaints, and ant-
acids in cases attended with an unhealthy
accumulation of acid;  and secondly,  all
such as relieve inflammation, comprehend-
ing demulcents, emollients,  refrigerants,
and the whole list of evacuants.
   2.  In the second division are embraced
those medicines which,  by some unex-
plained influence upon the nervous sys-
tem, correct its painful irregularities, with-
out impairing its healthy powers; such as
carbonate of iron and sulphate of quinia
in neuralgia, and ammonia and other in-
citants without  narcotic properties, in  the
purely spasmodic affections.
   3.  The third division is that to which
the term anodyne is most usually applied,
and to which it  ought, perhaps, to be  re-
stricted.  It consists of those medicines
which, by a direct influence on the brain,
diminish  its  capacity  for receiving  im-
pressions, and consequently render it more
or less insensible to those of a painful  na-
ture. These are the only medicines which
relieve pain  under all circumstances and
from whatever causes, and therefore pre-
eminently merit the name.  They might,
at first sight appear to claim considera-
tion as a distinct class;  but  they all be-
long to the narcotics, and, as their property
of relieving pain is merely incident to  the
more general power over the  cerebral
functions by  which this class is  charac-
terized,  they will be more conveniently
treated of under the same head.   It may
here be observed, that they are highly use-
ful in a wide circle of  diseases,  not only
by contributing to the comfort of the  pa-
tient,  but also  by relieving  the system
from the excessive and often exhausting
irritation of pain and  consequent wake-
fulness,  which  often aggravate  existing
diseases,  and render an otherwise mild
case alarming if not dangerous.  In their
employment,  however, reference should
always be had to their narcotic  and fre-
quently stimulant properties, and the pos-
sible aggravation which these properties
may occasion in inflammatory affections,
especially of the brain  or its membranes.
Care should,  moreover, be taken, when
they are used in inflammations,  that  the
relief which they afford to the pain, should
not be mistaken for  a  subsidence of  the
disease itself.   Otherwise, the organic af-
fection, which is not necessarily  mode-
rated by the remedy, may go  on increas-
ing unobserved, and may be undermining 
22                             ANOM— AN OS.
 the citadel  of life, while its advances are
 masked by  the defences erected to ward
 off its open assaults.
   Comparatively few of the narcotics are
 habitually used as anodynes.  Of these,
 opium is incomparably the most effectual.
 Hyoscyamus and lactucarium are occa-
 sionally  substituted,  when this remedy
 acts unfavourably from peculiarities in the
 constitution of the patient, or the nature
 of the disease.  Camphor is also frequently
 used  in reference to its anodyne proper-
 ties.   Conium, belladonna, and stramoni-
 um, have, to a certain extent the same
 effect; but  they are generally prescribed
 rather with a view to their supposed agen-
 cy in subverting the existing morbid ac-
 tion, than merely for the relief of pain.
                       Geo. B. Wood.
   ANOMALOUS  (From a priv. and
 cyMaoj, regular.)  Irregular,  contrary  to
 rule.  A disease is called anomalous which
 cannot be referred to any known species ;
 or in  whose symptoms and progress there
 is something unusual.            I. H.
   ANOMOCEPHALUS.  (From a priv.,
 vouo$,  rule, and xtfyaTur;, head.)   Geoffrov
 St. Hilaire has  bestowed this epithet
 upon one of his genera of monsters, which
 comprises  all  those  individuals whose
 heads are deformed.  (See Anencephalus,
 Monsters, &c.)                  I. H.
   ANOMPHALOS.   (From  o priv. and
 oufyahos, umbilicus.)  Without a navel.
                                I. H.
   ANORCHIS,   or   ANORCHIDES.
 (From a priv. and o^ij, testicle.)  With-
 out testicles.                    I. H.
   ANOREXIA, or ANOREXY. (From a
priv. and ogi-fa, appetite.)  Want of appe-
 tite, inappetence,  absence of  desire  for
food without loatbing.  It may exist in va-
rious degrees, from simple diminution of
appetite  to  complete inappetence.  The
seat of appetite appears to be the mucous
membrane of the stomach; and inappe-
tence is a frequent result of all the patho-
 logical conditions of that tissue.  In some
of the most serious disorganizations of the
 stomach,  as softening, ulceration, and in-
duration,  it is often  the  only symptom
which indicates these diseases.  Its utility,
however, as a diagnostic sign,  is lessened
by the fact of its sometimes existing for a
long period without the stomach present-
 ing after death any appreciable lesion,
 and, on the other hand, lesions of this vis-
 cus are sometimes unattended with any
diminution of appetite.  Anorexia occurs
not only in the primary diseases of the
stomach,  but also when this  viscus be-
 comes secondardy affected; it  is thus fre-
 quently present  in  almost all the acute
 phlegmasia and  in  many chronic affec-
 tions, and indicates that the stomach sym-
 pathizes in the sufferings of the other or-
 gans.  It must be manifest from this view
 of the subject that anorexia is not  pro-
 perly a disease as it  was considered by
 the nosologists, but  a symptom; the ex-
 pression of some pathological condition of
 the gastric mucous membrane. The treat-
 ment of anorexia must  of course  be  di-
 rected to the cure of the disease of which
 it is the symptom.  In  most cases, ano-
 rexia indicates the inaptitude of the sto-
 mach to receive food, and it  must then be
 considered as  a useful signal exhibited by
 nature  for  the necessity  of abstinence.
 Nothing can  be  more injurious in such
 cases than the too frequent practice of at-
 tempting  to excite the appetite, by  sto-
 machics as they are termed, most of which
 are strong stimulants, as the bitters  and
 bitter and aromatic tinctures, which infal-
 libly excite or aggravate the irritation of
 the stomach, and lead to  serious and often
 to fatal disorganizations of this  viscus.
 (See Gastritis.) Sometimes, though rarely,
 anorexia results from a state of asthenia
 or atony of the stomach,  as  in convales-
 cence from certain diseases;  occasionally
 from prolonged or rigid  abstinence;  and
 where the  irritability or excitability of the
 stomach has been exhausted  by the habit-
 ual use of  stimulating food or drinks.   In
 such cases, the bitter tonics  may be use-
 ful.  They should be conjoined with nu-
 tritious food, exercise in the open air, and
 carbonated chalybeate waters.  (See Con-
 valescence, &c.) When anorexia is caused
 by excessive indulgence in opium,  tobac-
 co, or similar  articles, their  use  must be
 abandoned.  If the loss of appetite is the
 consequence of literary labour, too seden-
 tary habits, grief, or violent passions;  the
 cessation of study, amusements, riding or
 other exercise, change of residence, &c,
 are to be recommended.  In short, the dis-
 ease, of which anorexia  is the symptom,
 must be sought for, and  the  remedies be
 directed to its  cure. (See Appetite, patho-
 logical conditions of, Dyspepsia, &c.
                             I. Hays.
  ANORMAL, or,  more  properly, AB-
 NORMAL. (From ab, without and norma,
 rule.)  Irregular, not conformable to rule.
                                I. H.
  ANOSMIA.  (From o priv. and osur;,
odour.)  Diminution or loss of the sense of
 smell. The seat of this sense is the mucous
membrane, lining the superior portion of
the nasal  fossa; but an essential part of
the mechanism of all sensations is their 
ANTA.—ANTH.
23
transmission to the brain, and  their per-
ception by or repetition  in this  organ.
Anosmia may result from a pathological
condition, either primary or secondary, of
any portion of this apparatus: it is a symp-
tom  of such lesion.  It occurs in coryza;
in irritations productive of suppression of
the secretion of this tissue;  in ulcerations
of this same membrane, &c.  It also occurs
in various lesions of the olfactory, of the
fifth pair of nerves, and of the portion of
the brain appropriated  to the perception
of odours.  It is sometimes congenital,
from a vice of conformation; remarkable
instances of which have been  related by
Deschamps and Breschet.
   The treatment  of  anosmia .must of
course be directed to the removal of the
diseases of which it is  but  the  symptom,
and will be pointed out in the proper arti-
cles.  (See Smell, pathological states of,
&c.)                        I. Hays.
   ANTACIDS,  or  Anti-acids.  (From
0**1, against and acidus, acid.) Substances
 which possess the property of correcting
acidity, especially in the stomach.    They
all act chemically,  by uniting with the
acids, thus neutralizing them; such are
the alkalies, magnesia,  &c.  (See Dyspep-
sia, Cardialgia, &c.)             I. H.
   ANTAGONISM.  (From urn,  against
and  ayuvi^tw, to act.)  The   resistance
 which two opposite forces offer  to each
 other.                           I. H.
   ANTAGONIST.  This  term  is em-
 ployed in anatomy to designate  certain
 muscles whose action is in an opposite di-
 rection to that of others.   Thus  the ex-
 tensors  and the flexors are reciprocally
 antagonists; so also the abductors and ad-
 ductors, the pronators and supinators, &c.
 As  there  is no motion in one direction
 without a capability of it in  another, every
 muscle has its  antagonist.   Without this
 arrangement all movement would be im-
 possible,  as is shown by the phenomena
 of paralysis.   Thus, in hemiplegia, the
 muscles of one side having lost their con-
 tractility, those of the opposite  side are  no
 longer counterbalanced in their action,
 and they draw the parts to which they are
 inserted, out of their situation;  and hence
 the distortion of the mouth.      I. H.
   ANTAPHRODISIAC,   and  ANTI-
 PHRODITIC.   (From wti, against, and
 oujj^oSnty, venus.)  Remedies which dimin-
 ish  or abolish the venereal appetite. By
 the ancients, several articles,  as the Ag-
 nus castus, Nympheea  alba, and Camphor,
 were supposed to be endowed with this
 special property; but  the  moderns have
 denied the possession,  by  any medicine,
of such powers.  The term antaphrodisiac
has consequently fallen into nearly entire
disuse, or there  are  arranged under this
head, only those general debilitants and
hygienic measures which act upon  the
whole system, and thus diminish the sen-
sibility or orgasm of the sexual organs.
Some facts which  have been  recently
communicated to us,  seem  however to
show that we really possess a remedy, viz.,
the Dulcamara, which enjoys antiphroditic
powers.   We are indebted for a know-
ledge of this, to our venerable and respect-
ed friend Dr. Dewees.   This careful and
accurate observer informs us that he was
led to the discovery of the property just
noticed,  in the  dulcamara, from the  cir-
cumstance of a gentleman who was taking,
by his direction,  a decoction of the plant
(1 oz. to a pint of water, the whole in di-
vided doses during the day) for the  cure
of an herpetic affection,  complaining that
his venereal  appetite  had ceased.  The
medicine was discontinued, and the patient
was restored to his usual state. To ascer-
tain whether  or  not the  loss  of venereal
appetite was really the effect of the action
of the dulcamara, Dr. D. requested his pa-
tient to resume the use  of the medicine,
and the same result followed; it was again
discontinued,  and the  effect  ceased.  Dr
D. has since  seen the same phenomenon
follow the use of this medicine under simi-
lar circumstances.   This has led  him to
 prescribe it in two cases of nymphomania
and one of satyriasis, and with the  most
 successful results. Our friend Dr. Thomas
 Harris, to whom these facts had been com-
 municated, informs  us that he has admin-
 istered the article  in five  cases, and in
 every one its use was followed by an ex-
 tinction of the venereal appetite; which,
 however, returned after the medicine was
 discontinued.
   The further  discussion of this  subject
 here, would  involve repetition;  we  will
 therefore refer the reader to the articles,
 Dulcamara,  Nymphomania,  Onanism,
 Priapism, and  Satyriasis, where it  will
 be considered in all its details.
                             I. Hays.
   Antiversion  of  the Uterus.   (See
 Uterus, Displacements of.)
   ANTHELMINTICS.    (From  «*t,
 against, and tXfuvs, a worm.)  Under this
 title, in its most extensive signification,
 are included  all medicines calculated to
 free the alimentary  canal from the worms
 with which it may  be infested, or to pre-
 vent their generation in cases in which a
 predisposition to them  may exist.  But,
 considered as the name of a distinct divi- 
24
ANTHELMINTICS.
sion in a  systematic arrangement of the
Materia Medica, the term has a more li-
mited application.   The  class of anthel-
mintics, strictly speaking, embraces those
medicines only which prove noxious or
poisonous  to the worms by a direct action
upon them; not such as operate against
these parasites  by their  influence on the
functions  of the stomach and bowels, in
other words, by means of properties which
are incident to them as members of other
classes.  Emetics  and cathartics, there-
fore, though frequently very efficacious in
the expulsion of worms, and tonics, though
useful in  preventing their subsequent de-
velopment cannot properly be considered
as belonging to the class of anthelmintics;
as their influence  depends on those very
qualities which entitle them to the rank
of emetics, cathartics, and tonics.  An ac-
count of these latter remedies, in their re-
lation to verminose complaints, belongs to
a pathological and  therapeutical treatise
on worms, and to this head the reader  is
referred.  In the present place  we shall
speak of anthelmintics only in the limited
acceptation above explained.
   These medicines relieve the alimentary
canal from the presence of worms, either
by occasioning their death, and  thus ex-
posing them, like other lifeless matter, to
the expulsive or digestive  powers of the
stomach and bowels; or by so far debdi-
tating them as to  disable them  from re-
sisting the peristaltic motion, especially
when increased by purgatives; or finally
by rendering their situation in  the body
uncomfortable, and thus disposing them to
escape with  the  feculent  matter, or, as
sometimes happens, along  with  the  con-
tents of the  stomach in vomiting.
   Their operation upon  the worms  may
be either  poisonous or mechanical. There
is no doubt that some medicines prove fa-
tal or noxious to  these  animals without
affecting  the human system injuriously.
Thus, worms are  sometimes discharged
dead, after the administration of an an-
thelmintic which produces  no unpleasant
effect upon the patient; and, if introduced
into an infusion of certain  vermifuge me-
dicines out of the body, they die much
more speedily than  when immersed  in
pure water.  There is  reason to believe
that worms in the upper bowels and sto-
mach are sometimes partially  or com-
pletely digested, after  having  been de-
stroyed by the medicine administered;  as
fragments of the animal are occasionally
found in  the discharges from the bowels,
and symptoms of stomachic worms, of the
 most unequivocal character, have disap-
peared under the use of the oil of turpen-
tine, without any appearance of worms in
the evacuations.
  There seems  to be no  good reason for
the scepticism which has been entertained
by some in relation to the mechanical ope-
ration of certain anthelmintics.  It may be
true that a substance  capable of injuring
or destroying worms in this way, may also
irritate to a certain extent the alimentary
canal; but leaving out of the question the
protection  afforded to  the lining  mem-
brane of the stomach and bowels by the
mucus which covers  it, we may readily
account for the  comparative  impunity of
the patient, by reflecting upon the circum-
stances of position which more completely
subject the worm to the action of the  ir-
ritant, and upon the relative extent of sur-
face exposed, which,  in the one instance,
is the whole body of the animal, in the
other,  only a small  portion,  at any one
time, of the alimentary mucous membrane.
An  experiment made by Mr. Chamber-
laine satisfactorily proves that cowhage
at least operates mechanically as a vermi-
fuge. Among some round worms contain-
ed  in a calabash,  he sprinkled the sharp
hairs of the pod of the Dolichos pruriens.
At first no visible effect was produced;
but very soon the worms began to writhe
about and evince signs of extreme pain;
and, on examination by the microscope, it
was found that the hairs had in several in-
stances penetrated deeply into the body.
   It has been conjectured that the  fixed
oils, such as olive-oil and castor-oil, which
have sometimes been  given as  anthel-
mintics, prove fatal to the worms by pre-
venting the access of air, which is as ne-
cessary to their existence as to that of
other animals.
   The  number of substances really or
conjecturally  possessed  of anthelmintic
properties, and  which have, at  various
tunes, and in different parts of the world,
been employed  in verminose  complaints,
is very great.  Among those which may
be considered most efficacious, and in dif-
ferent times and places have enjoyed the
highest popularity, the following may be
enumerated:—Azederach (bark of the root
of the Melia azederach), Bear's foot (Hel-
leborus fetidus), Cabbage-tree bark (Geof-
froya inermis, or Andira inermis),  Cam-
phor, Cowhage (setse of the pods of the
Dolichos pruriens), Male fern (root of the
Aspidium Filix Mas), Mercury, OU of
turpentine, Pink root (Spigelia Mariland-
ica), Pomegranate root, Rue, Savine, Tin
in powder or filings, Tobacco, Wormseed
of the Levant and Barbary (dried unex- 
ANTHEMIS.                              25
panded  flowers, &c. of different species
of Artemisia), and Wormseed of this coun-
try (Chenopodium anthelminticum).  Bit-
ters, which undoubtedly serve, in some in-
stances, by their tonic property, to put the
stomach and bowels in a condition unfa-
vourable to the production and sustenance
of worms, are thought by some to be di-
rectly noxious  to  the animals, and there-
fore properly anthelmintic.   The alkalies
and alkaline earths, which have also been
found useful in verminose complaints, pro-
bably act merely  by their antacid proper-
ty.   There is reason to believe that some
of the purgatives are  anthelmintic, inde-
pendently of their cathartic  powers, par-
ticularly aloes and calomel, the former of
which  probably acts immediately on the
worm,  the  latter  through  the agency of
the very acrid bile which it often occa-
sions the liver to secrete.
                       Geo. B. Wood.
   ANTHEMIS.  (Botany.)
   Sex. Syst.   Syngenesia  Superflua.—
Nat. Ord. Compositae Corymbiferre.
   Gen. Ch. Receptacle chaffy. Seeddown
none, or a membranaceous margin.  Calyx
hemispherical, nearly  equal.  Florets  of
the ray more than five. Willdenow.
   1.  A. Cotula.—May-weed,  Wild chamo-
mile.—Camomille puante, Maroute, Fr.;
Hunds-Kamille, stinkende Kamille, Germ.
—Sp. Ch. "Receptacle conical; chaff se-
taceous ;  seeds naked; leaves bipinnate;
leaflets subulate,  three-parted." Willde-
 now.  This is an annual plant, with an
erect, striated, branching stem, from one
to two feet high,  bearing alternate, ses-
sile,  doubly or triply pinnate leaves, with
linear,  pointed, and smooth  or somewhat
hairy leaflets.  The flowers are compound,
with a yellow disk and  white ray, and
stand singly on the summit of the branches.
The calyx is  hemispherical, and consists
of linear imbricated scales.  All parts of
the plant have a disagreeable fetid odour,
and a warm bitter taste.  It is a native of
Europe, and grows wild in abundance in
the United  States, though  supposed to
have been introduced.  It is found along
the roads, among rubbish, and in waste
places about towns and villages.  Its flow-
ers appear in  July, and continue till late
in the autumn.
   The  may-weed yields its  properties of
smell and taste, together with its medical
virtues, to water.  Its effects upon the sys-
tem are those of a mild tonic; and it may
be used for the same purposes as officinal
chamomile, though much more disagree-
able. Its fetid odour  has  led to the im-
pression  that it possesses antispasmodic
   vol. ii.          3
powers; and hence it has been given in
hysteria and other nervous complaints. It
has also been employed as an emmena-
gogue;  but probably acts, like most other
herbs given in the state of hot infusion, in
amenorrhoea, only by the warmth of the
vehicle united with  the  slightly excitant
property of its volatile oil. In this country,
the plant is scarcely employed in regular
practice.   The whole herb is active ; but
the flowers are preferred for internal use,
on  account of their  less disagreeable fla-
vour.  The form of administration usually
preferred is that of infusion.  On the con-
tinent of Europe, a strong infusion is used
as an enema in nervous complaints.
  2. A. nobilis.—Chamomile, Roman cha-
momile. — Camomille,   Camomille Ro-
maine, Fr.; romische Kamille, edle Kam-
ille, Germ.—Sp. Ch.  " Leaves bipinnate;
leaflets three-parted, linear-subulate, some-
what vdlose; stem branching at the base."
Willdenow.  Chamomile is  a perennial
herbaceous plant with several stems, from
six inches to a foot long, horizontal  at the
base, erect at the extremities, more or less
branched, smooth below, and downy above.
The  leaves  are alternate,  bipinnate, and
covered with  a very  fine  pubescence,
which gives them a grayish-green colour.
The  leaflets are small, slender,  pointed,
und divided into two or three lobes.  The
flowers are  solitary and terminal, with  a
yellow convex disk and white ray.   The
calyx is hemispherical, and composed of
several small, imbricated,  hairy scales.
The florets of the ray are numerous, nar-
row, and terminated by three small teeth.
   The plant is a native of Europe, where
it is abundantly cultivated for medical use.
It has been introduced into this  country,
and may be observed in some places grow-
ing wild.  In our gardens  it is cultivated
as  a domestic medicine, the whole herb
being employed in the form  of  infusion.
It flowers  in June and July.  All parts of
the herb  have a peculiar fragrant  odour,
and a bitter aromatic taste, and all possess
medical virtues; but the flowers  only are
officinal.  (See Chamomile.)
   3.  A. Pyrethrum.—Pellitory of Spain.
—Pyrethre, Fr.; Bertram-Kamille, Germ.
—Sp. Ch. "Stems simple, one-flowered,
decumbent; leaves pinnate, many-cleft"
Willd. Sp. Plant.  The root of this plant
is perennial, long, tapering, furnished with
small fibres, and of a whitish colour ex-
ternally.   It sends up several herbaceous
stems, which are usually  simple, round,
trailing at the base, erect at the extremity,
scarcely a foot high, and terminated by a
solitary flower.  "The leaves  are doubly 
26
ANTHRAC—ANTHRAX.
pinnate, with narrow linear segments of a
pale green colour.  The flowers are large
and beautiful, with a yellow disk, and rays
which are white on the upper surface, and
purple beneath.  The plant is a native of
the Levant Barbary, and the Mediterra-
nean coast of Europe.  It is said to be cul-
tivated  in Thuringia,  in Germany;  but
this is probably a mistake.  As described
by Hayne, the plant there cultivated is
different from the A. Pyrethrum of Lin-
n.eus, and has been placed by the former
botanist in a different genus, with the title
of Anacyclus officinarum. It  is an annual
instead of a perennial plant aQd though it
may,  as stated, produce a kind of pellitory
used  in Germany,  is  certainly not  the
source of the medicine  usually kept  in
the shops under that  name.   The dried
root of the A. Pyrethrum is the part em-
ployed as a medicine.  (See Pellitory.)
   Besides the species of Anthemis  above
described, two others have been noticed by
medical writers—the A. arvensis, and  A.
tinctoria. The former is an annual plant,
growing wild in Europe and this country,
and bearing  flowers which,  though ino-
dorous, have an acrid bitter taste, and pos-
sess medical properties  resembling,  but
inferior to, those of common chamomile.
The latter is a native of Europe, where it
has been used  as a  tonic and vermifuge,
but is  wholly unknown in  the United
States.  Its flowers are said to  be employed
to dye a yellow colour.
                      Geo.  B. Wood.
   ANTHRACOSIS. (From avOeai, coal.)
AvOeojcuot-s, Gr.;  Anthracia,  Carbuncula
palpebrarum, Lat;  Charbon des paupi-
eres, Anthracose, Fr.; Augenbrand, Germ.
Anthrax of the eye-lids.  This  is a rare
affection.  The subjects of its attacks are
principally the dregs of society, those who
are ill fed, filthy, and  addicted to intem-
perance,  and persons  in advanced life,
though M. J. Cloquet has met with it in
a young peasant girl  (Diet  de Med.  II.
459.). Its seat is most generally the upper
lid.  It presents itself in the  form of a tu-
mour of a dark red or purplish colour, ac-
companied with violent shooting, burning
pain; grayish vesicles  rise on its surface,
which burst  and  discharge  an ichorous
matter; the cellular membrane and skin
affected slough, and a cavity  is left which
is filled  with sanies:  often,  according to
Weller  (I. 120.), no  vesicles form, but
the tumour more  or less speedily passes
to a state of gangrene,  sloughs out, and
leaves a cavity which discharges a sanious
humour.
  The causes of this disease are the same
as those of anthrax elsewhere.
  The prognosis is usually unfavourable;
for  if death does not result from the con-
sequent fever, the eye-lid may suffer a
loss  of substance, whence result a con-
traction and eversion of the part (Lagoph-
thalmia), and sometimes even the loss of
the  eye.
  No  peculiar treatment is  demanded
for anthrax  in this situation, except that
care should be taken to keep the eye-lids
closely approximated  during the  whole
course of the healing process, in order to
prevent their retraction and eversion. (See
Anthrax.)
  Bibliography.—Wenzel.   Manuel de VOcu-
liste, ou Diclionnaire Ophthalmologique.  Paris,
1808.  L 162.
  J. Cloquet. Art. Anthracose, in Diet, de Med.
Paris, 1821.
  Weller.   Traiti  thior. el prat, des Malad.
des Yeux. Trad, de l'Allemande sur la 3me ed.
Par  F. J. Heister, &c.  Paris, 1832.   I.  120.
  Mackenzie,  tract. Treatise on the Diseases
of the Eye. Lond. 1830, and Boston, 1833. p. 109.
                             I. Hays.
  ANTHRAX.  (From tulgog, coal.) oj»-
6pa%, Gr.; Anthracia,  Carbo, Carbuncu-
lus,  Persicus ignis, Lat.; Charbon, Fr.;
Karbunkel, Germ.; Carbuncle, Eng. This
disease does not differ essentially from the
common boil or  furuncle,  either  in  its
cause, location, or career.  Like that well-
known affection,  it may be caused by di-
rect local irritations applied to the skin,
or may follow, sympathetically, certain af-
fections  of  the  gastro-intestinal mucous
surface.  The formidable,  and frequently
fatal consequences of the complaint result
from the greater  extent of the parts  in-
volved, and the consequent severity of the
febrile and  other  phenomena, which pre-
cede or follow its attack.
  Furuncle (q. v.) is an inflammation of
the  cellular  tissue occupying one  of the
conical or cylindrical areolae of the cutis
vera, and it  terminates in  gangrene of the
part affected, in consequence of the stran-
gulation of the tumour, by the firm fibrous
envelope of the areola.   In anthrax, the
inflammation is  extended  to many proxi-
mate areolae at the same time, all of which
become gangrenous, and involve also the
death  of the fibrous partitions which di-
vide  them.   The  disease  then, to use the
words of MM. Roche and Sanson, con-
sists  in  an  agglomeration of furuncles.
(Nouv. Elem. de Pathologic I. 278.)
  The parts most subject to anthrax are
those  in which  the skin  is  thickest, and
contains the  largest portions  of cellular 
NTHRAX.
27
tissue within  its substance; such as the
neck, the back, the parietes of the thorax
and  abdomen, the  nates, the thighs, the
shoulders, &c, and it not unfrequently in-
vades the jaw. The disease is not strictly
confined to the skin, but frequently  in-
volves the subcutaneous tissue to  a con-
siderable extent, particularly in situations
where this tissue is least lamellated in its
arrangement  aud perhaps  no part  of the
surface is entirely exempt from its attacks.
It appears as a very hard  and painful tu-
mour, well defined or circumscribed; of a
deep red, or  livid colour,  surrounded by
a circle of erysipelatous inflammation; the
pain, as in all inflammatory affections of
the  skin, being of the burning character,
and rapidly increasing in intensity, till the
gangrene supervenes. It attacks the aged
and debilitated,  more frequently than the
young and healthful. In females it occurs
more frequently, about the period  of the
cessation of the menstrual flux.
   The causes which predispose to this pe-
culiar form of inflammation are not well
understood, but they seem  to be analogous
to those which  produce  erysipelas  phleg-
monoides, and diffuse inflammation of the
cellular tissue.  Habitual excess in eating
and drinking, not only  increases the lia-
bility to anthrax, but renders it much more
 dangerous when it does  occur. It happens
 occasionally as  a sequence to  herpes, the
 itch, measles, small-pox, and  other cuta-
 neous diseases; or it may  be more imme-
 diately  produced by punctures, friction, or
 any other local irritation to the skin.  It
 is  often preceded by lassitude, thirst, or
 foul tongue, fever, and the other customary
 marks  of gastro-intestinal irritation,  and
 it then makes its appearance without  any
 obvious local cause. M. Marjolin remarks
 that it  occurs  more frequently in  spring
 and autumn, than in summer and winter;
 which  appears to  prove   that  cold  and
 dampness, and the vicissitudes of tempe-
 rature,  may contribute  to its production.
 (Diet, de Med.  Ed. 2.)  We have noticed
 a much greater liability to its  appearance
 in seasons when there  exists an epidemic
 tendency  to  erysipelas  phlegmonoides,
 with which  it  is  sometimes complicated.
 (See  Surgical Works of John Jones, p.
 173.) It is sometimes critical  in fevers.
   The  progress  of anthrax has been di-
 vided into three stages, that of the inva-
 sion, that of the maturation,  and that of
 the ulceration  of the tumour.  The first
 stage commences frequently with a sense
 of itching in the  part affected, and this is
 sometimes followed by severe lancinating
 pains before the tumour attracts attention.
More frequently,  the  swelling is the first
local symptom noticed, and the disease is
generally mistaken for a boil  or  furuncle.
The  tumour rapidly  increases, and  the
pain  takes  on a  peculiarly severe,  in-
tense, burning character.   Medical aid is
then  called in,  and the surgeon finds  a
swelling presenting the appearances al-
ready noticed, which continues to increase
in size for  eight or ten days, and is then
enlarged in some cases to an  enormous
extent.  M. Marjolin (Loc. Cit.) mentions
a case in which it involved more than one
fourth of the surface of the neck, and an-
other, in which it covered the greater part
of the right flank. During this period, the
pain  increases continually,  until,  in se-
vere cases, it becomes intolerable.  Sleep
is prevented, frequently spasms  and deli-
rium are induced, and gastro-intestinal ir-
ritation, with its usual consequences, makes
its appearance,  or, if it pre-existed,  it is
now greatly exacerbated.  An  erysipela-
tous  circle  often surrounds the  tumour to
the distance of many inches.
   The  second stage  dates from the  mo-
ment when the  strangulation of the in-
flamed  parts in the centre of the tumour
has reached its  maximum, and death of
the  cellular tissue in  that  place  is  pro-
duced.   The  suppurative  process is  now
established, the skin over the most promi-
nent point  is gradually  thinned, and  at
length several little vesicles appear, burst,
and give exit, each, to a small  portion of
sanguinolent pus, generally of an unhealthy
character.  These vesicles are sometimes
confluent, and resemble one large phlyc-
tena.   In furuncle, where but one of the
 cutaneous areola?  is  affected  with gan-
 grene, a single orifice suffices to evacuate
 the pus; but in anthrax, where many are
 implicated at once, each requires to be se-
 parately discharged,  for the fibrous parti-
 tions between the  areola? render the per-
 colation of a fluid from one to another ex-
 tremely slow and difficult, even  after gan-
 grene  has  taken place.   In a  few days,
 many of these orifices  are fused into one,
 by the ulceration of the skin, and the dis-
 charge is increased  in quantity.   While
 the centre of the tumour is thus softened
 and converted into a slough,  the mass con-
 tinues hard for some time, and the circum-
 ference goes on enlarging.  After a time,
 the whole interior of the tumour becomes
 gangrenous, the livid pellicle of skin which
 covers its circumference  is  thin and  irre-
 gular,  the orifice presents a large slough,
 of a whitish or gray colour, covered by an
 abundant  discharge  of   pus resembling
 flour and water, and exhaling a fetid odour 
23                               ANTHRaa.
of a peculiar kind.  The suppuration sur-
rounds the base of the tumour, distending
the subcutaneous  cellular  tissue,  whicti
becomes involved in the gangrene  to a
greater or less extent  and when, in the
third  stage, the  dead  matter  has been
thrown off,  layer by layer, the parts pre-
sent the appearance of one  wide ulcer,
laying bare the aponeuroses, beneati 1 which
it occasionally  penetrates, sometimes ex-
posing the neighbouring muscles as com-
pletely as  if they were dissected.   The
edges  are thin, irregular, blueish, and in-
dolent, remaining indisposed  to, or inca-
pable of, adhesion with the parts beneath.
The loss of substance in severe cases is
very great and when the parts have cica-
trized, the contraction  consequent to the
destruction  of so much skin often occa-
sions serious deformity and limits the mo-
tions of the part. The pain, which reaches
its acme at the commencement of the se-
cond stage, continues, but gradually de-
clines, till its conclusion.
   The chief danger of the  third  stage
consists in the exhaustion consequent upon
the excessive discharge.  The whole dura-
tion of the disease, calculated to the time
when the sloughs are entirely separated, is
commonly from twenty to thirty days, but
no accurate limit can be set to the period
required for cicatrization.  Such  is  the
usual march of the local symptoms in an-
thrax,   unless  some peculiarity  in  the
treatment prevents their development.
   There are, however,  some  other conse-
quences, resulting from the particular situ-
ation of the tumour.  These are,  embar-
rassments of the functions of the neigh-
bouring  parts,  produced by the excessive
irritation and  pain attending the disease,
such as difficulty of deglutition, when the
tumour is on the neck;  dyspnoea, when it
is in the same situation, or on the parietes
of the  thorax; obstinate constipation, when
it is located upon the abdomen;  &c. They
require  no further comment  to  render
them  intelligible.  The disease is some-
times  accompanied by an eruption of nu-
merous furuncles, some of which may be-
come  involved  in the tumour so as to in-
crease its size, and occasionally,  several
tumours are found on the same patient at
the same time. (Marjolin.  Op. Cit.) Scat-
tered  petechia? are noticed by Pearson as
an occasional attendant on anthrax. (Ele-
ments of Surg, pt I.)
   Prognosis.  The prognosis in anthrax
depends  much on  the constitution  and
habits of the patient but still more on the
 location of the tumour.   Mild or small tu-
mours situated on the back or extremities
are rarely dangerous, and when large, the
danger results either  from the excessive
nervous irritation, or from the exhaustion
produced by the discharge.  On the con-
trary, when anthrax is seated over serous
cavities, even when moderate in size, it is
extremely prone to produce inflammation
of those  cavities.   This disposition  is so
remarkable in the head, that Sir A. Coop-
er  declares  he has  never  witnessed a
recovery from anthrax on the scalp.   Se-
rious  mischief is sometimes produced by
the  extension  of  the irritation  to the
nerves, when the  tumour  is seated over
the spinal column, especially in the neck;
and the  oesophagus and trachea  are en-
dangered when they pass near the site of
the disease.
  Treatment. The  apparent confusion ob-
served in the practical directions  of vari-
ous authors who have treated on anthrax,
seems to result, mainly, from a neglect of
the various characters assumed  by the
disease in its different stages, and in pa-
tients of different constitutional peculiari-
ties.  No one plan of treatment is adapted
to every  case, and every stage, of anthrax.
A strong distinction exists  between  those
cases which are consequent upon  some
important visceral irritation, and those in
which the tumour is the first obvious symp-
tom.  In the former, the relief of the pri-
mary visceral derangement should be the
first object of the surgeon, nor can he rea-
sonably anticipate success if he neglects
it; while in the latter, the tumour is the
most  important subject of attention in the
first instance;  for  the  disordered actions
of the various internal organs being a con-
sequence of the local affection, they are
most effectually corrected  by the  mitiga-
tion or destruction  of their cause.  Again;
there  is  as great a difference between
those cases which occur in persons whose
constitutions are  broken  down by  long-
continued excesses in eating or drinking,
and those which affect patients of mode-
rate habits and a correct life.  Where  the
former may require the internal exhibition
of bark, wine,  cordials, &c,  as  recom-
mended  by  Pearson, Hosack, and  many
other writers who have preceded or  fol-
lowed them, the latter may recover  much
better under a  rigorous diet, and local de-
pletion,  as prescribed  by A. Perrez, and
others of the physiological school.  In the
local treatment, also, the stimuli that may
prove useful in the second and third stages
of the disease, may be injurious in the first
stage. No doubt every plan recommended 
ANTHRAX.                               29
by surgeons of eminence has its valuable
applications in some of the various condi-
tions which have been mentioned.
  The days have passed, when surgeons
endeavoured to explain the obstinacy and
fatal effects of these tumours, on the sup-
position that they result from a peculiar
malignant virus  in the  system; and the
general treatment  of anthrax being now
regulated on the same  principles which
should guide us  in other severe local in-
flammations attended with similar consti-
tutional conditions and accidents, we shall
confine our remarks, at present  to the va-
rious local  remedies and modes of treat-
ment which have been prescribed  in  this
disease.
   a.  Repercussion by cold.  M. Marjolin
remarks that he has seen a mild anthrax
arrested in its progress, and the intolera-
ble pain promptly relieved, by the appli-
cation of compresses wet with  very cold
water. He objects to this remedy in cases
consequent upon an  internal cause,  and
adds, that it would speedily determine a
gangrene of the part,  if employed where
the inflammation in the tumour is intense.
(Loc. Cit.)
   b.  Antiphlogistics.  It has been but too
customary with some English and Ameri-
can surgeons to commence the use of sti-
mulating  washes and  cataplasms, in the
first stage  of anthrax.   The French, on
the  contrary,  direct  the  patient  to be
placed  on  a very  rigorous diet,  and to
drink freely of mucilaginous fluids, while
warm and emollient washes are applied to
the tumour during the height of the  in-
flammation. When the disease is produced
by an external cause, they endeavour to
arrest its progress by the  application of
numerous  leeches,  encouraging the flow
of as much blood as possible from the ca-
pillaries, by warm ablutions.
   By some of the disciples of Broussais,
this remedy is carried to greater lengths.
Dr. Perrez published, in 1825, a most in-
teresting case of anthrax, of large dimen-
sions,  treated  successfully by  repeated
leeching,  and rigid abstinence  from  all
food; emollient drinks, only, being allow-
ed.  It is remarkable that  the tumour in
this case  was preceded by gastric symp-
toms, of some continuance, and  that mor-
tification had taken place to a considerable
extent before medical aid  was  called in.
The patient was  a female, aged  39 years,
of a sanguineo-nervous temperament. She
had very severe constitutional symptoms,
convulsions, and  a  small, hard,  and very
frequent pulse.  (Ann. de la Med. Physio-
logique. VII. 583.)
  Although it is difficult to believe  that
this plan of treatment would succeed in
most cases of anthrax, and especially in
such as originate from internal causes, it
should be borne in mind, by those  who
would make a fair estimate of the value
of local depletion in this disease, that long
after the centre of the tumour has become
gangrenous and commences to suppurate,
the circumference often continues  in a
state of the highest inflammation, and may
therefore require the  employment of the
same  measures that are best suited to the
first stage.
  c. Opiates.   The  excessive  pain  pro-
duced by anthrax demands the attention
of the surgeon,  not only in consequence
of the distress  and loss of rest which it
produces, but also because of  the very se-
rious sympathetic affections which it may
engender in other parts, and the collapse
which sometimes occurs in the worst cases.
Patients have been known to die from the
latter effect, in the first stage of the dis-
ease.   Very great benefit sometimes re-
sults from  the  internal exhibition  of opi-
um; but it should be  avoided, or given
with great caution, when cerebral symp-
toms, or constipation are present.  In  such
cases, relief sometimes follows the appli-
cation of an opiate poultice, which should
be thin  and light, for the weight and pres-
sure of cataplasms render them very trou-
blesome to the patient.
  d. Incisions. These have been employ-
ed in the treatment of anthrax, since the
days of Ambrose Pare, if not at a still
earlier  period; but the manner and the
purpose of the incisions have been  very
various,  and this variety has been too
much neglected by the opponents of the
measure.
  The  plan of excision has had, and still
retains, some advocates; but this proceed-
ing cannot be resorted to, except when the
tumour is small, and even then, its severi-
ty,  and the fears of the patient, will sel-
dom admit  of its employment.  Professor
Lallemand resorts to a middle measure;
he surrounds the tumour by a circular in-
cision, for the double purpose of depleting
the capillary  vessels and  relieving the
strangulation of the parts.  This incision
is only applicable when  the tumour  is
small, and when there is no danger of di-
viding any considerable artery  or  nerve.
The portion of skin included in the cir-
cle, together with  the subjacent cellular
tissue, becomes gangrenous, and is thrown
off  in  a slough. (Marjolin. Loc. Cit.)
This method may very probably limit the
extension of the anthrax, but it can have 
30                               ANTHRAX.
little  effect in relieving the strangulation
of the inflamed  parts; which arises, not
from any general constriction of the whole
mass, but from the unyielding character
of the fibrous areola? of the  skin.  This
fact is indeed proved by the result, for if
the constriction were removed, the gan-
grene would be prevented.
   Decidedly the best form of incision is
the crucial; and the credit of having first
directed it for the express purpose of re-
moving strangulation, is claimed,  by his
pupils, for M. Dupuytren.  This form of
incision was directed by many of the older
surgeons, in the second stage of anthrax,
for the purpose of evacuating the  eschars
and the pus.  Its employment  for this  pur-
pose  was opposed by Lamotte, because
there are many purulent depots  in an-
thrax, and they are not all opened by this
operation. ( Trait e Complet de Chirurgie.
t1. ed. 3.) Lassus advocates  it for giving
free access to the pus.  (Pathologie Chi-
rurg. 11.)   In  1788, J. Pearson  speaks
of incisions and caustic as justly exploded
(Principles of Surgery,  pt 1. 136.), yet
they are now generally employed in Eng-
land,  and receive the sanction of Sir A.
Cooper.  (Loc. Cit.)   M. Dupuytren  re-
sorts to the crucial incisions, even  in the
first or forming stage of anthrax. He car-
ries them entirely through and beyond the
edge  of the tumour, and when it is very
large, he makes additional incisions round
the  circumference,  in  the  intervening
spaces.  After carefully pressing out the
pus infiltrated into the cellular tissue,  or
inclosed in the skin,  if any has been se-
creted, the wounds are dressed with sim-
ple emollient poultices; and if the pa-
tient's condition demands it his strength
is supported by some mild tonics or bitters.
When the anthrax  is attacked in time,
and when it is effectually divided by the
incisions, it  is said never to terminate in
gangrene.  (Codet.  Diss, sur VAnthrax.
p.  17.)
  The success attending this plan of treat-
ment, in  the  Hotel Dieu, would  amply
warrant a far more general recourse to  it,
than has yet been made in the  United
States. A case is narrated by John Jones,
of New-York, in which he  speaks  of the
advantage gained by the crucial incision
in alleviating the  sense of constriction,
prior to 1795  (Surgical Works, p. 173.);
and the measures of Dupuytren were fol-
lowed in several cases, with the happiest
effect at  the  Belleville  Almshouse,  be-
tween the years 1817 and 1821. (C. Drake,
M. D.  In N. York  Med. Repns.  N. S.
VI. 462.)  Yet  it  is evident  that there
must be many cases in which these inci-
sions are inadmissible or  impracticable,
owing to the great extent, or the location
of the disease; and it should not be for-
gotten that the relief of the strangulation
and  consequent pain is  but  partial, for
many of the areola? remain untouched by
the knife, and  inflammation may continue
violent  in the  intervals of the incisions.
This plan of treatment has been objected
to, by many, on account of the increase of
irritation produced;  but this is certainly
an erroneous objection.  The local bleed-
ing far more than compensates for the mo-
mentary increase of  symptoms from the
pain of the  operation.
  e. Epispastics.  The treatment  of an-
thrax by epispastics,  may  be considered
purely American.  Riverius, indeed, pre-
scribed  them long ago, as  Dr. Beck ob-
serves, but appears to have employed them
as counter-irritants, and applied them, not
to the tumour  itself, but to some neigh-
bouring part (Obs. Med. Cent. IV. 7.) Dr.
Physick, who was  the originator of this
plan of treatment, seems now to repose less
confidence in  it than formerly.   "From
the great power of blisters in checking
mortification," he remarks,  " I once enter-
tained high expectations of their utility in
the treatment of anthrax.   But though I
have found them serviceable in  abating
the burning  pain attending  the inflamma-
tion, they have not shown  any power in
counteracting  its progress to mortifica-
tion." (Phil. Journ. of the Med. and Phys.
Sciences. II. 175.) Still there is evidence
enough  to show that these  remedies pos-
sess a high value in certain cases, and it
is desirable  that future observers should
endeavour to determine the precise cir-
cumstances  under which they prove most
useful.  Although they may sometimes ac-
celerate rather than retard the mortifica-
tion of the centre of the tumour, where they
very seldom produce  vesication, they ap-
pear  to  circumscribe the  inflammation,
and thus prevent the extension of the dis-
ease. The proper period for their employ-
ment would seem to be  the  commence-
ment of the second  stage,  and the most
suitable cases,  those  in which the extent
or location of the tumour  interdicts the
use of the knife, and which show a strong
tendency to spread indefinitely, or  to be-
come complicated with diffuse inflamma-
tion  of the cellular tissue.   A blister has
been known almost immediately to cause
a complete line of demarcation, when the
mortification of an anthrax of the worst
character was  rapidly spreading.   There
is a most interesting anonymous case, of 
ANTHRAX.
31
this  character, in the JV. E. Journal of
Medicine and Surgery.  IX. 337.)  The
tumour was seated over the first cervical
vertebras, so as to extend some inches on
the scalp. Very dangerous cerebral symp-
toms supervened, but they yielded readily
to the blister.  Drs. T. D. Mitchell and
J. B. Beck have also furnished  us with
6ome  important  observations illustrative
of the use of epispastics in the treatment
of anthrax.  (See Bib. to this Art.)
   As a means of affording temporary re-
lief, Dr. Physick informs us that he is in
the habit of resorting to blisters, when  an-
thrax is attended with that excessive pain
which  is compared by the patient to  the
application of burning coals.  The relief
they afford is great but it rarely continues
beyond twenty-four hours;  their applica-
tion may,  however, be  repeated as occa-
sion requires.  Dr. Physick employs  the
blisters, under these  circumstances, even
in the first stage, or, to use his own words,
" as soon as the disease is certainly known
to be anthrax."
   f. Cautery. The employment  of caus-
tics, in the cure of anthrax, is of very  an-
cient date, and a variety of them  have
been recommended for this purpose.   Ar-
senic was used as early as the  days of
Agricola : Le Dran employed corrosive
sublimate, and Riverius,  some others.
Celsus depended mainly upon  the actual
cautery, which he applied after  dividing
the  eschar, so as to permit the heat to  act
upon the living parts beneath.   It would
be more curious than  useful to  relate
the  opinions  and arguments of  the sup-
porters and opponents of this plan of treat-
ment  Suffice it to say, that the greatest
objection advanced against it—the severi-
ty of the  application—is  more  specious
than real.  It must be remembered that in
this  disease, the extreme branches of  the
nerves of feeling are inflamed and pressed
on in such a manner as to experience  the
highest possible degree  of irritation,  for
this  irritation  goes  on  increasing  until
it deprives them  of life  : how then can a
remedy which accomplishes the  destruc-
tion of these parts almost instantaneously,
produce more pain than the slower torture
of the disease ? We have had occasion to
witness the application of the actual cau-
tery, in several cases of severely painful
disease,  notwithstanding the  very infre-
quent  employment  of  this measure  in
America, and we can bear testimony to
the fact that  the application of an iron at
a white heat produces very little  pain: at
a less temperature, its effects  are indeed
severe, because  it does not then destroy
the cutis instantaneously.   Surely there
can be no more  effectual mode  of remov-
ing the mechanical causes of the violence
of this disease, than the destruction of the
parts by  cautery, after all hope of resolu-
tion is at an end.  Many authors object to
cautery when the disease affects the face,
for the same reason  that Marjolin pro-
scribes incisions under the same  circum-
stances, to wit,  because  of the deformity
likely to result from the application! This
is strange; for  neither  remedy is advo-
cated except in cases which are, or will
inevitably become, complicated with gan-
grene, which accident must induce still
greater deformity, if the case is left to na-
ture.  The happy effects of the actual cau-
tery, employed after the manner of Cel-
sus, are illustrated in a case of anthrax of
the face, by M.  Pouteau. (QZuvres Pos-
thumes.  II. 515.)
   The potential cautery  is  considered by
many as more painful  than the actual;
and from the few instances in which we
have  employed or witnessed  the  applica-
tion of the latter, we have been  inclined
to the same opinion ; but the highest sur-
gical  authority in America stands in some
degree opposed to us.  Dr. Physick thinks
that the rapidity of action displayed by
the caustic potash, which  certainly ren-
ders it much less severe than any other
agent of the same class, is productive of
less suffering to the patient than even the
heated iron.  Caeteris paribus,  the alkali
will always receive a general preference
to the iron, in this country, because of the
terror inspired in the patient by the latter
measure, and the natural aversion of the
surgeon to a plan of treatment so alarm-
ing to the friends and  attendants.  But
there is still another and a stronger argu-
ment advanced by Dr. Physick.  He thinks
that the ulcers  resulting from  burns  are
always unhealthy, and peculiar; whereas
those that follow the application of caustic
potash are simple, healthy,  granulating
sores. The former have a strong tendency
to form irregular callous ruga? in the cica-
trices, and almost always heal with diffi-
culty.  The latter, on the contrary, cica-
trize  readily,  and  leave a smooth sur-
face, productive of little deformity. (See
Burns.)  He  has therefore recommended,
and continues to employ, the caustic al-
kali, in preference to  the actual cautery,
in the treatment of anthrax.   The proper
time for the application of this remedy is
the commencement of the  second stage,
when the orifices begin to form  in the 
32                                 ANTHRaa.
6kin; and it should be carried to such an
extent as to destroy the vitality of all that
portion of the cutis vera which would ne-
cessarily become gangrenous if it  were
omitted.   We are  indebted for this view
of his opinions,  to  the politeness of Dr.
Physick himself.
  The use of caustic at an early period,
when all stimulating applications are inju-
rious, Dr.  Physick  considers as the chief
cause of the opposition raised  against it
(Loc. Cit.)  A moment's reference to the
pathology of the disease will show the ad-
mirable adaptation  of this remedy to the
complaint.   The degree of relief experi-
enced from it may be fairly judged from
the  history of the  case of the  late Mr.
Wharton.  "At this  period," i. e. at the
commencement  of  the second  stage,  on
the  morning of the tentl< day,  says Dr.
Physick,  "I suggested  the application
of the  vegetable alkali  upon the middle
of the tumour,  for  the  purpose of de-
stroying all that part of the skin perfo-
rated by the orifices just mentioned.  This
was  immediately submitted to, and an es-
char formed, of about two inches in diam-
eter.  The pain from the caustic ceased
in a quarter of an hour, and from that time
Mr.  Wharton suffered no pain  whatever
from the disease," &c. (Loc. Cit.)
  g.  After-treatment.  During  the whole
course  of the complaint, care  should  be
exercised to keep the bowels as regular as
possible; and when the sloughs are  sepa-
rating, and after they have been detached,
it is often necessary to support the strength
of the patient with mild tonics, and some-
times with cordials  and stimulants.  If
neither incisions nor caustic have been re-
sorted to, the edges of the ulcer are rag-
ged, thin, bluish, and ill disposed to  unite
with the parts beneath;  they should then
be removed,  either by  the knife  or  by
caustic. The ulcer should be treated upon
general principles, as it has nothing pecu-
liar in its character. (See  Ulcer.)   Parti-
cular  care is necessary  in  lessening as
much as possible the deformity and em-
barrassment of motion resulting from the
loss  of substance.  (See Cicatrix.)
  The term anthrax has been  applied to
certain other tumours, especially to the
bubo (q. v.), which occurs in plague, &c,
but  there  is little  in common between
these affections.

  Bibliography.—Celsus.  De Midicina.
  Tosi, (Antonio.) De Anthrace seu  Carbun-
culo Traclatus. Venetiis, 1576. 4to.   lb. 1618.
  Perez de Herrera. (Christophe.) De Car-
bunculis Animadvertiones.  Pintise, 1604. 4to.
  Riverius, (L.)   Observationes Medica el Cu-
raliones insignes.   Haga-Comitis, 1656.  4to.
  Frank, (G.)  De Carbunculo.  Heidelburga:.
1682.  4to.                   _.     .  _
  Lamotte. Traiti Completde Chirurgte.  lorn.
I. ed. 3.  Paris, 1722.
  Bordenave, (T.) De Anthrace. (Diss. Inaug.)
Parisiis, 1765. 4to.                     .
  Bcjecking, (J. J. H.)  De Carbunculo Bentgno.
(Diss. Inaug.)  Helmstad, 1771.  4to.—Ibid. Der
Gudartige Karbunkel, &c. Stendal, 1786.  8vo.
  Pouteau. OEuvres Posthumes. Tom. II. Pa-
ris, 1783. 8vo.
  Pearson, (John.)  Principles of Surgery,  pt.
1.  London, 1788.  8vo.
  Latta, (J.)  A  System of  Surgery.  Edin-
burgh, 1795. 8vo.
  Jones, (John.)   Surgical  Works of the tale
John Jones.  Edited  by Dr. Mease.  Philad.
1795.  8vo.
  Art.  Anthrax, in Encyclopedic Methodique.
Partie Chirurgicale.
  Chatenet, (Fr.) Essai sur VAnthrax. These.
Paris, an. XI. (1800.)  8vo.
  Lassus.  Pathologie  Chirurgicale.   Tom. I.
Paris, 1806.   8\o.
  Larrey.   MJmoires  de Chirurgte  Militaire.
Vols. 3.  Paris, 1812. Trans, by R. W. Hall. I.
51.  Baltimore, 1814.
  Mouton.   Art. Anthrax, in  Dictionnaire des
Sciences Medicales.  Paris, 1812.
  Codet, (P. J. A.) Dissertation sur VAnthrax.
These.   Paris, 1813.  4to.
  Mitchell, (T. D.) Anthrax successfully treated.
New-York Med. and Phys. Journ.  N. S.  II. 64.
(1815.)
  Richerand.   Nosographie Chirurgicale.   I.
210.  Ed. 4. Paris, 1815.
  Vergnies, (F. A.)  Considirations  sur VAn-
thrax non-contagieux. These.  Paris, 1815.
  A case of Anthrax.  New England  Joum. of
Medicine and Surgery.   N. S.  IV. 337.  Boston,
1820.
  Drake, (C.)  A  case  of Anthrax.  New-York
Medical Repository.  N. S.   VI. 462.   1821.
  Physick,  (P. S.)   A  case of Carbuncle, with
some remarks on the use of caustic in that disease,
in Philad. Journ. of the Med. and Phys. Sc.  II.
172.  (1821.)
  Beck, (J.  B.) A case  of Anthrax  successfully
treated.  New-York Medical  and Physical Jour-
nal.  II. 37. 1823.
  Hosack (David.) Essays  on various subjects.
II. 256.  New-York, 1824.
  Cooper, (Sir A.)  Lecture on Gangrene.  Lon-
don Lancet. I.  245.   1823.—Ibid.  Lectures by
Tyrrel. I. 242.  London, 1824.  8vo.
  Freeman, (D. C.)  Case of Anthrax, in N. Y.
Medical and Physical Journal.  III.  252.  1824.
  Townsend, (P.)   Letter to Dr. Hosack, on a
case of Anthrax.   New-York Medical and Phy-
sical Journal.  III. 335.   1824.
  Gibson, (W.)  Institutes of Surgery.  Vol. I.
Philad. 1824.
  Boyer.   Maladies Chirurgicales.  Tom. II.
Paris, 1825.
  Perez, (Auguste.) Observation d'un Anthrax
traiti physiologiquemcnt, el guiri, in Annales de
la  Medecine Physiologique.   VII.  583.  Paris,
1825.
  Roche and Sanson.   Nouveaux  Elimens de
Pathologie.  Ed. 2. I. 278.  Paris, 1828.
  Sanson.  Art. Anthrax, in Diet, de Med. et de
Chirurg. Prat.  III. 26.   Paris, 1829.
  Marjolin.  Art. Anthrax, in Diet, de Mede-
cine.  Ed. 2.  Paris, 1833.
  Richter.  Anfangsgr. de  Wundarzn. b. 1.  .
                      Reynell Coates. 
ANTHR.—ANTIDOTE.                         33
  ANTHROPOLOGY. (From «$£<«««
man, and toyoj, discourse.)  A discourse
or treatise on man, or  the  science of hu-
man nature.  In its fullest application, An-
thropology is the history of man as a part
of creation, whether he be considered in
reference to his  organization, his physio-
logical  endowments, his intellectual and
moral attributes, or the zoological position
he  occupies  in the great scale of animal
existence. In this acceptation it is a kind
of generic term, embracing the entire his-
tory of man, both corporeal and spiritual,
in all his multifarious relations. Consider-
ed  in reference  to the physical organiza-
tion of man, anthropology becomes merged
in anatomy;  when applied to the investi-
gation of his vital  economy, it identifies
itself with physiology; and when its ob-
ject is  his intellectual and moral  endow-
ments and relations, it naturally becomes
blended  with psycology or metaphysics,
and may hence be  made to embrace the
doctrines "of theology, ethics,  jurispru-
dence, politics, &c.
  A much better plan is to  limit the term,
as has been done by some writers, to the
natural history of man, and to employ the
word anthropology in  reference  to this
subject in the same manner that the terms
ornithology, entomology, conchology, &c,
are used to designate the natural  history
of birds, insects, and the molluscous ani-
mals.   For the details of the subject con-
sidered in this manner, see Man.
                        E. Geddings.
  ANTHROPOMORPHOUS. (From av-
J^wrtoj, man, and uoe$tj, form.)  Having
the human form.                  I. H.
  ANTHROPOTOMY. (From «&gw*os,
man, and tofitw,  to cut.)  Literally, the
dissection of the human body. In its more
common acceptation, the term anthropoto-
my is synonymous with anatomy, and is
employed to represent human anatomy, in
contradistinction to zootomy, which is the
anatomy of animals.             E. G.
  ANTI, and, by abbreviation,  for the
sake  of  euphony,  ANT.   (From  am,
against.) Opposed or contrary to. This pre-
position, prefixed to an adjective, serves,
in therapeutics, to designate the measures
suitable  for the cure of a  disease or re-
moval of a symptom.    Thus, antiphlogis-
tics, are the measures employed  for the
cure of inflammations, &c.  Anti, in this
view,  is  synonymous  with remedies  or
therapeutic agents.
  The expression anti, is sometimes used
to indicate remedies which possess a con-
stant efficacy against certain affections, as
in the words  anticancerous, antisyphilitic,
&c.; it is here synonymous with specifics
(q. v.).
   To constitute  a class of remedies, it is
necessary that there should be an analogy
between the individuals which compose it.
Such analogy is, however, rarely met with;
and moreover, the phases of diseases  are
so various, that  remedies suitable in  one
stage or  to one person, are inapplicable in
another stage or to another person, and to
effect a  cure  it is necessary  to have re-
course to a different class of  therapeutic
agents.  Hence, but few of these classes
should be admitted, and we shall accord-
ingly reject all but those which appear
well founded, or the epithets applied to
which are so  commonly employed that a
definition will be expected;  the others
will be treated of in  the articles on  the
several diseases, to which, indeed, they
really belong; for the  employment  of all
remedies involves pathological considera-
tions from which the  therapeutic cannot
be  separated without  inconvenience.
                             I. Hays.
   ANTIDOTE.  (From avtt, against,  and
SiSwoa,, to give.) Antidotes are substances
which, when administered, have the pow-
er of rendering poisons  inert, or at least
devoid of danger.  According to its ety-
mology, the term would include every re-
medy which might with propriety be em-
ployed in cases of poisoning; but  in its
modern acceptation, it is restricted to such
agents only, as have the power, to a great-
er or less extent of acting chemically on
poisons in the stomach, with the  effect
of destroying their dangerous properties.
Agreeably to this definition, the nature of
such bodies is more correctly conveyed by
the term Counter-poisons.
   According to Orfila, the first authority
on  this subject,  antidotes or counter-poi-
sons should possess the five following pro-
perties :
   1. They should admit of being taken in
large doses without danger.
  2. They should act on the poison at or
below the temperature of the  body.
   3. Their action should be prompt
  4. They should have the power of com-
bining with the poison in the midst of the
gastric, mucous, bUious, and other fluids,
which the stomach is likely to contain.
  5. And lastly, in acting on  the poison,
they should possess the power of depriv-
ing it of  all deleterious properties.
  in investigating the subject of antidotes,
toxicologists have instituted a  great num-
ber of experiments on inferior animals.
To guard against erroneous conclusions,
it is necessary in these experiments, after 
34                               ANTIDOTES.
the ingestion of the poison and the anti-
dote,  that the  oesophagus  of the animal
should be  tied;  as otherwise  vomiting
might produce  a relief, which would  be
erroneously attributed to the influence  of
the antidote.  Even when the experiment
is thus performed,  Orfila  cautions  us
against drawing too hasty a conclusion;
as the results are rendered ambiguous by
the varying degree  of vitality of the ani-
mal experimented on, as well as by the
effects of the ligature itself.
   The number of antidotes as yet disco-
vered is but limited, compared with  the
great number  of  poisons known; and
those which are recognized  as such, act
with various degrees of power and prompt-
itude, even  when given under the most
favourable circumstances.
   The different recognized antidotes will
be  noticed in this place, only in a gene-
ral manner; because they are necessarily
treated of, in detail, under the head of the
different poisons against which they  are
used.
   The  substances  for which  antidotes,
more or less efficient, have been discover-
ed, are, 1. mineral  acids; 2.  oxalic acid;
3. fixed alkalies;  4. ammonia; 5. alka-
line sulphurets;  6. alkaline  earths;  7.
the  salts  of the following metals; viz.
antimony, silver, copper, lead, tin, and
mercury.  To this list may be  added opi-
um and its preparations.
   Mineral Acids. These acids, embracing
the  sulphuric,  nitric, and muriatic,  act
with  extreme  promptitude,  and require
the application  of antidotes with the least
possible delay.  The best antidote which
can be  employed is calcined  magnesia,
which acts by neutralizing the particular
acid,  converting it into a saline combina-
tion which  is  comparatively innocuous.
But as the greatest danger arises from the
least delay in the application of remedial
measures, and as magnesia is not always
to be had immediately, it will be the duty
of the practitioner to use less efficient an-
tidotes, until that earth can  be procured.
Accordingly, in the interim, strong soap
suds, or  soft soap  and water, should  be
administered freely.   If these are  not
at hand, the patient should  be made to
swallow large quantities  of mucilaginous
drinks, of milk, or  even  of warm or cold
water, while the  magnesia is being pro-
cured. When this is obtained, the patient
should be gorged with water in which the
earth has been plentifully stirred.   The
carbonate of magnesia, though highly use-
ful in the absence of the pure  earth, is less
convenient than the latter; as its employ-
ment gives rise to a prodigious distension
of the stomach, in consequence of the ex-
trication of carbonic  acid.
   Oxalic Acid.  From the fearful rapidity
with which  this poison acts, it has gene-
rally produced fatal mischief before assist-
ance can be afforded.  The proper anti-
dotes in poisoning by this acid are chalk
and  magnesia, speedily given, in large
doses suspended  in water.   They act by
forming with the poison an insoluble  ox-
alate of lime or of magnesia.  In case  the
appropriate  antidotes are not at hand,  the
practitioner may, while  they  are being
procured, administer  an emetic; but Dr.
Christison cautions against the adminis-
tration of warm water, as, in his opinion,
the dilution of the poison will promote its
absorption, and thereby increase its dele-
terious effects; unless free vomiting should
speedily occur, which is not always  pro-
duced by giving warm water.
   Fixed Alkalies.  The only fixed alka-
lies which are known to act as poisons are
potassa and  soda. Lithia, though probably
poisonous in the caustic state, has not been
experimented upon with a view to its ef-
fects. The combinations in which potassa
and soda are caustic  and poisonous,  are
the hydrates and carbonates, known under
the names of caustic potassa and soda, car-
bonate of potassa, (potash,  pearlash, and
salt of tartar,) and carbonate (subcarbon-
ate) of soda.
   The proper antidote for these alkalies,
according to Orfila, is vinegar, very much
diluted, and taken in  large quantities.  It
acts not only by neutralizing the poison,
but by favouring its  expulsion  by vomit-
ing.  If vinegar should not be at hand at
the first moment of the accident the pa-
tient should be gorged with simple water,
or some mucilaginous drink, until vinegar
and  water  can be  procured.  According,
however, to M. Chereau, sweet oU  is a
preferable  antidote  to vinegar.   It  acts
partly  by rendering  the vomiting more
easy, and partly  by converting the poison
into soap.   When oil is employed, it usu-
ally requires to be given to the  extent of
several  pounds.
   Ammonia.  The same antidotes appli-
cable to the treatment of the fixed alka-
lies, are also proper here.  Unfortunately,
however, this alkali,  in the caustic liquid
state, acts with such extreme promptitude,
that very little can be hoped from the  use
of antidotes.
   Alkaline Sulphurets. These sulphurets,
the principal of which is the sulphuret of
potassa, sometimes called liver of sulphur,
act as poisons probably in consequence of 
ANTIDOTE.                               35
the rapid disengagement in the stomach
of sulphuretted hydrogen, which is a high-
ly poisonous gas.  The proper antidote is
chloride of  soda,  or chloride  of lime,
(bleaching salt) given in solution. It acts
by  decomposing the poisonous gas,  the
chlorine of the antidote uniting with its
hydrogen,  and precipitating the sulphur.
While the antidote is preparing, some di-
luent must be administered in large quan-
tities without the least delay.
   Alkaline Earths.  The  alkaline earths
for which  antidotes are known are  lime
and baryta.  Those for lime are precisely
the same  as for the fixed alkalies,  enu-
merated above.   The  antidote  for  ba-
ryta,  or its soluble  salts, particularly the
muriate, which is very poisonous, is a so-
luble sulphate, which acts by converting
the earth  into the  insoluble sulphate of
baryta.   Accordingly, in the treatment of
these cases, weak solutions of sulphate of
soda,  or of sulphate of magnesia, should
be given; but at the same time, the expul-
sion of the poison should be attempted by
titillating the throat with a feather, or by
the administration of an emetic.
   Salts of Antimony.  The principal salt
of antimony, and that most likely to pro-
duce  poisonous effects,  is tartar emetic.
In treating  a case of poisoning by this
salt Orfila advises, provided the patient
has vomited  freely  soon after the inges-
tion of the poison, and is not affected with
sharp pains, that warm water  should be
administered freely. In case vomiting has
not taken place, it must be induced, if
possible,  by  immediately  titillating the
throat with a feather, and  by the adminis-
tration of abundance of warm water. Sweet
oil sometimes favours vomiting, and  may
be useful.  If, notwithstanding the employ-
ment of these measures, vomiting is not
produced  in  a short time, recourse must
be had to a warm decoction of yellow Pe-
ruvian bark,  freely given,  which acts as a
proper  antidote, by decomposing the  poi-
son and rendering it comparatively inert.
This antidote was proposed by Berthol-
let,  and  Orfila  reports two  cases in
which its use was attended with complete
success.   Until the decoction is prepared,
the bark  in  substance,  diffused in water,
should be given.  If the bark is not at hand
under circumstances which would render
its employment  expedient it will be pro-
per, until it is procured, to  use, as a substi-
tute,  a decoction either  of galls, of some
astringent root or bark, or  of common tea.
All these vegetable substances act as an-
tidotes  on the same principle, namely,
that of decomposing the poison, and pre-
cipitating the protoxide of antimony in
union chiefly with tannin.
  Orfila says that the alkaline sulphu-
rets should be rejected as antidotes for tar-
tar  emetic.   Nevertheless, the late Dr.
Duncan asserted that he used for this pur-
pose the sulphuret of potassa with perfect
success.
  Salts of Silver.  All the soluble salts
of this metal are decomposed completely
by common  salt, which causes a precipi-
tate  in them of the insoluble chloride of
silver.  Of  the salts of this metal, the ni-
trate  only is likely to be taken in  a poi-
sonous dose; and when called to such a
case,  the physician should administer a
weak solution  of common salt in large
quantities.
  Salts of Copper.  The best  antidote for
these salts has been ascertained by Orfila
to be albumen, which possesses the  pro-
perty of decomposing all the soluble salts
of copper, and destroying their deleterious
properties.   Called to a case of poisoning
by copper, the physician should administer
a solution of the  whites of eggs  in  re-
peated doses, untU the stomach is liiled
with  this liquid, when vomiting will pro-
bably occur. Until eggs can be procured,
the patient  should be gorged  with  water,
and made to vomit, if possible, by exciting
the throat with a feather or the finger.
  Orfila has obtained equally favourable
results from the  use of the ferrocyanate
(prussiate)  of potassa as an antidote for
the cupreous poisons, as from the employ-
ment of albumen.  It acts by throwing
down an insoluble ferrocyanate of copper.
But as this antidote is not so easdy pro-
cured as eggs, and is apt  to produce ver-
tigo when given in large doses, it  is less
eligible than albumen.
  Sugar, announced by M. Marcelin Du-
val as an antidote to the poison of verdi-
gris,  has been proved by  Orfila  not to
possess that character, but merely to act
as a calmer of irritation.
  Salts of Lead.  Orfila  has proved that
the sulphate of magnesia, when taken in
sufficient quantity, is a true antidote to the
poison of acetate  of lead (sugar of lead)
recently taken in an over-dose. It acts by
producing in the  stomach, by double de-
composition, the insoluble sulphate of lead,
which is inert.  The same  toxicologist in-
fers from these facts that the sulphate of
magnesia would be equally efficacious in
destroying  the poisonous  effects of the
other soluble «salts of lead.  For the  poison
of lead, as displayed in its  remote effects,
in the affections called lead colic and lead
palsy, no antidote is known. 
36
ANTIDOTE.—ANTILITH.
   Salts of Tin.  The only salt of this me-
tal likely to prove poisonous is the  muri-
ate ; and for this, Orfila has discovered
that milk  is a complete antidote.  This
animal liquid combines with the salt and
becomes converted into thick curds.  It is
to be  administered  in large quantities,
mixed with water.
   Salts of Mercury.  The only prepara-
tion  of mercury important as a poison is
the deutochloride, or corrosive sublimate.
To Orfila belongs  the merit of having
discovered  that albumen or the  white of
eggs is a proper antidote to this energetic
poison.   It acts by converting the corro-
sive  sublimate into calomel,  with  which
the albumen then combines. Accordingly,
the first measure  to be taken by a practi-
tioner called to a case of poisoning by cor-
rosive sublimate, is to give several glasses
of the whites  of eggs,  mixed with water.
If eggs are not to be procured immediate-
ly, the  interval, until  they are  obtained,
should be occupied with the administra-
tion of flaxseed tea, rice water, sugar and
water, gelatinous broths, or even simple
warm water.  These diluents distend the
stomach, and by favouring vomiting, pro-
mote  the expulsion of the poison.
   Hydrosulphuric acid (sulphuretted hy-
drogen),  sugar, Peruvian bark, mercury,
charcoal, and broth, have all been proposed
as antidotes to corrosive sublimate; but
Orfila has proved that none of these sub-
stances deserve that title.  The gluten of
flour,  proposed in 1822 by M. Taddei as
an antidote for this poison, is  admitted by
Orfila to be  useful, but nevertheless in-
ferior to albumen.
   Opium and its Preparations.  The an-
tidotes which  have been proposed for opi-
um are 1.  coffee; 2. camphor; 3.  chlo-
rine  water;   4.  vinegar  and  vegetable
acids; 5. water and mucilaginous drinks;
6. decoction of galls.  Coffee and camphor
have no effect as antidotes, though  useful
in combating  the effects of  this poison.
Chlorine water is itself an acrid poison,
when given of sufficient  strength to de-
compose  the opium in the stomach.  Vine-
gar and vegetable acids are not antidotes,
since they have no power of decomposing
the poison  and destroying  its dangerous
qualities; and their effects are diametri-
cally opposite,  according as they are given
before or after the expulsion of the poison
by vomiting.   If before, they are hurtful
by promoting the solubility, and therefore
absorption,  of the opium;  if after, they
prove useful by diminishing the symptoms
caused by the  poison. These remarks ap-
ply  equally  to  water and mucilaginous
drinks.
   The decoction of galls may be viewed
in the light of an imperfect antidote to the
preparations of  opium; since it has the
power of producing a precipitate with them
which is much less active than the opium
itself.  Accordingly, Orfila recommends,
in cases of poisoning by opium, the ad-
ministration  of this decoction in repeated
doses.  A  detailed account of the  other
measures necessary to be pursued in cases
of poisoning by opium, would be out of
place under 'die head of Antidotes, and
will be given under the article Opium, to
which the  reader is referred.
   There still remain a number of poisons
for which antidotes are not known.  The
alkaline  sulphurets, sulphuretted hydro-
gen, acetic acid, charcoal, and lime-water
have been  recommended as antidotes for
arsenic; but Orfila declares that they
are all  without  any efficacy, except the
last, which may be useful, in case the poi-
son has been taken in a state  of solution,
by forming with it  the insoluble arsenite
of lime.  But as  Orfila  truly remarks,
inasmuch   as arsenic  is  almost  always
taken in the solid  state, lime-water can
rarely be of  any use.  Hydrocyanic acid,
like  arsenic,  has no antidote.
                    Franklin Bache.
  ANTIEPHIALTICS.    (From  «*»,
against and tfyiaxtys, nightmare.)  Reme-
dies for nightmare (q. v.).        I. H.
  ANTIHELIX.  (From am, before, and
taxi, the helix.)  An eminence of the car-
tilage of the ear, in front of the helix, ex-
tending from the concha of the auricle to
the groove of the helix, where  it termi-
nates insensibly  in a bifurcation.  I. H.
  ANTIHYPNOTICS.     (From  am,
against,  and v7tvo^,  sleep.)   Remedies
against sleep or drowsiness. Natural sleep
ought rather to be favoured than repelled;
but on  some occasions,  persons wish to
keep  awake, and this is  usually accom-
plished by the use of stimulants, as coffee,
tobacco, &c.  Morbid sleep, somnolence,
coma, (q. v.), arises  from various causes,
and the measures resorted to for its cure
must of course have reference to its cause.
There is no class of remedies entitled to
the epithet antihypnotic.          I H
  ANTILITHICS.  (From o*tc, against,
and **0oj, a stone.)   These are medicines
which have a tendency to prevent the de-
position of calculous matter in the kidneys
or bladder,  or to dissolve it when deposit-
ed.  It was formerly believed that stone
in the bladder might be destroyed by the 
ANTILITHICS.
37
agency of substances taken into the sto-
mach, and  to  these  substances  the  name
of Lithontriptics was applied ; but to say
the least such a power has never been
proved to be  possessed  by any medicine,
and certainly, therefore, cannot properly
serve  as the  basis of a class.  Still, the
painful effects of the stone may be consi-
derably alleviated,  and  its increase, per-
haps,  in  some instances, prevented or re-
strained ; and there can be no doubt that
the disposition of the kidneys  to secrete,
or of the urine  to deposit in the bladder
calculous matter in the form  of sand  or
gravel, may often be completely corrected
by  certain remediate measures.  It has
been  thought by some who reject the  li-
thontriptics, that the medicines calculated
to produce these effects might with pro-
priety, be associated into a class with the
name  of Antilithics,  which  merely ex-
presses their  efficacy in relieving  calcu-
lous affections, without  indicating  their
mode of action.  But  to such an associa-
tion, as to all others founded  on certain
pathological conditions, it may be object-
ed, that,  as these conditions often depend
upon different causes, are variously modi-
fied by circumstances, and  require  diver-
sified and  sometimes complicated modes
of treatment, the remedies employed must
vary,  and can possess no sufficient resem-
blance or unity of properties to authorize
their  arrangement into  a distinct group.
In relation to the antilithics, this will  be
rendered obvious by the few general re-
marks which  it is deemed proper to  make
upon  the medicines embraced under that
title.
  In certain morbid states of the system,
the uric or lithic acid, which is a constant
ingredient of the urine in its healthy state,
is thrown  off by the kidneys in unusual
abundance, and, as it can be held in solu-
tion by the urine only in moderate quan-
tities,  is  deposited  either uncombined,  or
in connexion  with  a portion of ammonia
or other alkaline base, usually in the form
of a reddish sediment  The disposition  of
the system which leads to this result, it is
customary to denominate the uric or lithic
acid diathesis.  As the  acid is rendered
soluble by an  excess of  alkali, it is obvi-
ous that alkaline remedies are here the
best correctives of the  calculous  symp-
toms;  for, by entering the circulation, and
passing out with the  urine, they enable
this liquid to hold in solution the substance
which would  otherwise be deposited.
  In the urine of a person in health, the
uric acid is held in solution through the
agency of the alkaline bases with which
  VOL. II.          4
it is combined.  As it has but a feeble af-
finity for these bases, almost  any  acid
which may be secreted by the  kidneys,
will, by depriving it wholly or in part of
the alkali, diminish its solubility, and fre-
quently cause its deposition.  The exist-
ence of acid, in large quantity, in the pri-
ma? vise, will, therefore, often give rise to
gravel,  in consequence of the absorption
of the acid, its passage into the circula-
tion,  and its evolution by the  kidneys.
The best antilithics are, here also, obvi-
ously,  the alkalies  and alkaline earths,
which neutralize the acid in the stomach
and bowels, and consequently prevent its
absorption.
  But the presence of  an  excess of acid
in the alimentary canal, is very often ow-
ing to a debilitated or dyspeptic condition
of the stomach, which  may be corrected
by the employment of gently excitant re-
medies.  Hence, tonics and  astringents
are occasionally useful as antilithics.
  There is reason to believe, that, in mor-
bid conditions of the system attended with
an  increased  production  of acid, nature
has provided that it should be  thrown  off
partly by the skin, and its accumulation in
the circulation, or undue direction to the
kidneys, thus prevented.  Whatever, un-
der these circumstances, checks perspira-
tion, must have a tendency to produce gra-
vel,  by directing the  superabundant acid
into the urine; and the restoration of the
function of the skin is clearly indicated as
a remedial measure.  Hence diaphoretics
are  sometimes useful in calculous com-
plaints.
  Not unfrequently a state of system ex-
ists which leads to the deposition  of the
insoluble  phosphates in the urine, and is
therefore sometimes designated  as the
phosphatic diathesis. The phosphoric acid,
existing in the urine, in a healthy state, is
variously combined with alkaline or earthy
ba^es,  and  held in solution  by a  nicely
balanced play of affinities, which may be
readily disturbed. The presence of an alkali
in excess will produce a precipitate of the
insoluble phosphates; and the habitual use
of alkaline medicines sometimes occasions
a deposition of this kind of calculous mat-
ter.   An acidulous state of the urine, on
the contrary,  has a tendency to keep the
phosphates in solution.  Acids, therefore,
prove antilithic in this form  of gravel,
both by preventing an excess of alkali in
the urine and by their own solvent power.
  The phosphatic diathesis is  often asso-
ciated with weak  digestion,  general de-
bility, and a deranged condition of the ner-
vous system; and  these  are  sometimes, 
38                 ANTILITHICS.—ANTIMONY.  (Chem.)
perhaps, the immediate cause of the un-
healthy action of the  kidneys.  Hence
tonics  and narcotics sometimes display
antilithic properties.
  When the calculous complaint is con-
nected with diminished secretion of urine,
there is an obvious indication for mild  di-
uretics with the copious use of demulcent
drinks, in order to dilute the urine and
thus increase  its  solvent power.  These,
therefore, may be added to  the  long list
of antilithics.
  Finally,  inflammation of the  kidneys,
acute or chronic, or a degree of  irritation
short of absolute inflammation, may so de-
range the action of these glands as to oc-
casion  the  production  of gravelly urine.
Consequently the antiphlogistic  remedies
may prove antUithic;  and  it is  probably
by their direct action upon the kidneys,  in
a state of chronic inflammation or ulcera-
tion, that certain stimulant diuretics, such
as copaiba  and the turpentines, are occa-
sionally useful in affections which pass
under the name of gravel.
  From this sketch it may be seen, how
exceedingly diversified are  the  remedies
entitled to the name of antilithic, and how
impossible it would be to associate  them
in a single class, characterized by any
one common property.  Of the  alkaline
antilithics,  those most commonly employ-
ed are the carbonates and bicarbonates of
soda and potassa, magnesia and its car-
bonate, and lime in the form of lime-water.
The bicarbonate of soda, perhaps, deserves
the preference both for  the comparative
mildness of its taste, and the promptness
and  certainty  of its action. It is most
agreeably administered dissolved in car-
bonic acid water, with or without a little
ginger syrup. The acids usually employed
as antilithics are the strong mineral acids,
such as the nitric, muriatic, and sulphuric.
Hard cider sometimes exercises a happy
influence in gravel, probably through the
agency of its acetic acid.  The most use-
ful diaphoretic is  the officinal powder of
ipecacuanha and opium, commonly called
Dover's powder.  Gentian, quassia, hops,
and  uva  ursi,  are  among the tonics and
astringents which have been particularly
recommended  in  gravel.   Opium  is the
most efficient  narcotic.  A  list of all the
antilithic remedies, and a precise account
of the circumstances  under which they
may be  most advantageously employed,
belong to a therapeutical treatise on cal-
culous disorders.       Geo. B. Wood.
   ANTIMONY.   (From the Greek am,
against, and French Moine, Monk;  in al-
lusion to the fact that when  first  used as a
remedy,  it was frequently given  by the
monks to  their brethren, in  hazardous
doses.)  Regulus of antimony; Antimo-
nium,  Stibium, Lat;  Antimoine,  Fr.;
Antimon, Spiessglas, Germ.; Antimonw,
Span., Ital.
  The number and importance  of the me-
dicinal preparations  of this metal render
it proper  that  it should  be  treated  of at
considerable length.  As an object of at-
tention by the physician, it deserves  to be
particularly studied in its chemical, phar-
maceutical, therapeutical, and toxicologi-
cal relations.  We shall, accordingly, treat
of it under the four following heads: 1.
Chemical history; 2. Pharmaceutical pre-
parations; 3. Effects on the system and
therapeutical applications; and 4. Toxi-
cological effects, and tests.
  § I. Chemical History.  The ores of
this metal were known from an early pe-
riod ;  but Basil Valentine was the first
who made mention of its reduction to the
metallic  state,  in a work entitled Currus
Triumphalis Antimonii, published towards
the close  of the fifteenth century. Of all
the metals, it was the one which attracted
the greatest  share  of attention from the
alchemists, and which was  subjected by
them  to  the  greatest number  of  experi-
ments. Since their time, it has been an ob-
ject of research with a number of the best
chemists, notwithstanding whose  labours
its chemical history  is still incomplete.
  Natural State and Mode of Extraction.
Antimony occurs native, in the state of
oxide, abundantly as a sulphuret and  rare-
ly as a sulphuretted  oxide.  It is found in
nearly all countries, but most abundantly
in France and Germany.  It is from the na-
tive sulphuret that  the antimony of  com-
merce is extracted.   The process pursued
in France consists  in first fusing the ore,
in order to separate the sulphuret  from
stony and earthy impurities.   It is  then
reduced  to powder and carefully roasted,
whereby, in  consequence of the dissipa-
tion of nearly all the sulphur, and the ab-
sorption of oxygen,  it is converted into an
oxide of a dull grayish-white colour.  This
is then mixed  with  tartar, or with  char-
coal impregnated with a concentrated so-
lution of carbonate of soda, and exposed
to heat in crucibles, in a melting furnace.
The charcoal employed,  or that derived
from  the decomposition  of the tartar, re-
duces the oxide; while  the alkali unites
with, and separates,  any small  portion of
sulphuret which may have escaped the
decomposing influence of the heat  The
metal obtained is then purified by a second
fusion. The antimony prepared in France 
ANTIMONY.   (Pliarm.)                         39
is  most esteemed, and is  that which is
principally received in the United States.
  Properties,  &c.  Antimony  is a  bril-
liant, brittle  metal of a lamellated  tex-
ture, of a silver-white colour when pure,
but bluish-white as it occurs in commerce.
When rubbed, it exhales a peculiar odour.
Its specific gravity is 6.7, and fusing point,
810°, or about a red heat. On cooling, after
fusion, it assumes a crystalline texture,
and an appearance on the surface, resem-
bling the fern leaf.  When strongly heat-
ed, it takes fire, and burns with emission
of copious white vapours, which condense
in  a brilliant, white, crystalline powder,
formerly called argentine flowers  of an-
timony,  which, according  to Thenard,
consist of protoxide. When a small portion
of the metal is fused, and thrown from
a  moderate height it separates into  nu-
merous burning globules, which leave a
white trace wherever they roll.  This me-
tal forms three combinations with oxygen,
one oxide,—the protoxide, and  two acids,
—antimonious and antimonic acid.  Ac-
cording to Berzelius, its equivalent num-
ber is 64.6; and the  oxygen in its oxide
and acids, is  in the ratio of the numbers
1£, 2, and 2\. Antimony also forms three
sulphurets, which  are  proportional, as to
the  sulphur which they contain,  to  the
three combinations with oxygen.
   Combinations with Oxygen.  The pro-
toxide may be  obtained by oxidizing anti-
mony by means of nitric acid, and  digest-
ing the resulting  compound repeatedly
with water,  until this liquid, poured off
from it, is no longer  capable of reddening
litmus.   The protoxide, thus obtained, is
in the form of a powder of a dirty white co-
lour.  It consists of one equivalent of an-
timony 646, and one and a half of oxy-
gen 12 = 76.6.  Antimonious acid, some-
times called deutoxide of antimony, is pro-
cured by oxidizing antimony at the ex-
pense of nitric acid, evaporating the mass
to dryness, and calcining the residue; or
by roasting the sulphuret of antimony, un-
til the whole of the  sulphur is  separated.
It  is a powder of a snow-white  colour,
which becomes yellowish on the applica-
tion of heat.  It consists of one equivalent
of metal 64.6,  and two of oxygen 16 =
80.6.  Antimonic  acid, called by some
chemists the peroxide, may be  formed by
dissolving the metal in nitro-muriatic acid,
evaporating the solution to dryness, add-
ing to the residue concentrated nitric acid,
and heating the mass  at a temperature
somewhat  under redness, until  all  the ni-
tric acid is expelled.  Antimonic  acid is
an  insoluble, tasteless powder, of a  pale
yellow colour when pure, but deep yel-
low when contaminated with nitric acid.
When exposed to a full red heat,  it loses
oxygen, and is converted into antimonious
acid.  It is soluble in a boiling solution
of caustic potassa,  from which it  may be
precipitated by acids as a white hydrate,
in which state it is slightly soluble in wa-
ter and reddens litmus.  It consists of one
equivalent of antimony 64.6, and two and
a half of oxygen 20 = 84.6.  These acids
form with ba^es, salts severally called an-
timonites and antimoniates.
   Chlorides.  Antimony forms three chlo-
rides, which are considered to correspond
in composition with its  three oxides and
sulphurets.  One of them is used in me-
dicine, and will be noticed hereafter un-
der the pharmaceutical preparations of the
metal. The other two are not of sufficient
importance to be described.
   The above sketch may serve  to give
the reader a general idea of  the chemical
properties and most important combina-
tions  of antimony.   With regard to the
properties of its numerous medicinal pre-
parations, these will necessarily be given
under the following head.
   { II.  Pharmaceutical Preparations.
The preparations of antimony which have
been  and are still used in medicine are
exceedingly  numerous; and to  notice
them  all would lead to tedious details, not
profitable  to the medical reader.  The fol-
lowing table may  be considered  as em-
bracing those pharmaceutical preparations
of antimony, which deserve particular
notice.   It  contains  nearly all  those  to
be found  in  the French Codex, and  in
the British and  United  States Pnarmaco-
poeias.
   Antimony  is used,—
Sulphuretted:
  1. Sulphuret  of  Antimony.  Antimonii
      Sulphuretum. Ph. U. S.
  2. Prepared  Sulphuret of Antimony.
      Antimonii Sulphuretum  Prsepara-
      tum. Ph. U.  S.
  3. Kermes Mineral.   Hydrosulfuretum
      Rubrum Stibii Sulfurati. Cod. Gall.
  4. Golden  Sulphur of Antimony.  Hy-
      drosulfuretum Luteum Oxidi Stibii
      Sulfurati. Cod. Gall.
  5. Precipitated Sulphuret of Antimony.
      Antimonii Sulphuretum  Prrecipita-
      tum. Ph. U.  S.
Combined with Chlorine :
   Butter of Antimony.  Deuto-Murias
      Stibii Sublimates.  Cod. Gall.
Oxidized :
  1. Powder of Algaroth. Antimonii Oxy-
      dum Nitro-Muriaticum. Ph. D. 
40                         ANTIMONY.   (Pharm.)
 2. Diaphoretic Antimony.   Oxidum Sti-
     bii Album.  Cod. Gall.
Oxidized and combined with Sulphu-
  ret:
 1.  Glass of Antimony.  Antimonii Vi-
     trum. Ph. L.
 2.  Crocus of Antimony.  Oxidum Stibii
     Sulfuratum Semivitreum. Cod. Gall.
Oxidized and combined with Sulphu-
  ric Acid :
    Subsulphate  of Antimony.  Sub-Sul-
     fas Stibii. Cod.  Gall.
Oxidized and combined with Tartaric
  Acid and Potassa:
    Tartar Emetic.   Antimonii et Potas-
     sse Tartras.  Ph. U. S. et D.
    a. Dissolved   in  wine.    Antimonial
     Wine.  Vinum Antimonii.  Ph.  U. S.
    b. Mixed with lard.  Tartar Emetic
     Ointment.    Unguentum   Tartari
     Emetici. Ph. D.
Oxidized and mixed with  Phosphate
  of Lime :
    Antimonial Powder.  Pulvis Antimo-
     nialis.  Ph.  L. et D.
  These various  preparations will be no-
ticed in succession, and more or less fully
according to their relative importance.
  Sulphuret of Antimony.  (Crude  Anti-
mony.)   This is  obtained from the native
sulphuret by a process of purification, the
object of which is to separate the earthy
and stony impurities, with which  the na-
tural ore is associated.   The best  method
for  effecting  this object is to place the
pounded  ore  in  slightly conical earthen
tubes, fixed vertically in a kind of rever-
beratory furnace.  Heat being applied, the
sulphuret the only part fusible of the ore,
will melt, and may be received below in
a proper recipient, while the impurities
remain behind.
  This preparation, sometimes called an-
timony,  and artificial sulphuret of anti-
mony, occurs in commerce in fused, round-
ish  masses, called loaves, of a dark-gray
colour externally, and of a brilliant steel-
gray colour and  radiated or  fibrous tex-
ture within.  Their goodness depends upon
their compactness and weight, the large-
ness of the fibres, and their total volatility
by  heat.  The quality  of the  sulphuret
cannot be judged of  except  in mass, and
hence it ought not to be bought in pow-
der.  The powder of the pure  sulphuret
is reddish-brown; that of the commercial
sulphuret almost always black. The most
usual impurities are lead, iron, and arsenic.
Lead  is  detected by the texture of the
loaves  being foliated;  iron, by the  pro-
duction of a brown colour by deflagration
with nitre;  and  arsenic, by the occur-
rence of an alliaceous  smell, when  the
sulphuret is heated.  This sulphuret con-
sists of one equivalent of antimony 64.6,
and one and a half of sulphur 24 = 88.6.
It is, therefore, a sesquisulphuret.
  Sulphuret of antimony is the parent of
nearly all the antimonial preparations, be-
ing the chief material from which  they
are made.   For medical use,  and for con-
venient pharmaceutical employment, it re-
quires to be levigated, when it constitutes
the following preparation.
  Prepared Sulphuret of Antimony. This
is merely  the preceding  preparation re-
duced to an impalpable powder,  by leviga-
tion and elutriation.  It is in the form of
a dull  black  powder, without  taste or
smell, and having a general resemblance
to powdered charcoal.
  Kermes  Mineral.  The true kermes is
not officinal in the British or United States
Pharmacopoeias; but is embraced  in the
French  Codex. This work directs it to be
prepared by the following process, which
is essentially that of Cluzel :—Take 1280
parts of rain-water,  and having boiled it
to free it from air, dissolve in it 128 parts
of carbonate of soda.  Boil the solution for
half an hour,  stirring it with  a wooden
spatula, and mixing with it 6 parts of sul-
phuret of antimony  in very fine powder.
Filter the  liquor into a vessel containing
warm water, previously freed from air by
boiling.  The liquor, as it falls into the
water, deposits a dark-red  powder.  After
it has cooled, decant the water and spread
the powder on a thick cloth, and wash it
with  boiled water,  first cold and after-
wards hot until the washings come off
tasteless.  Then submit the powder to the
action of a press to expel the water, dry
it in the shade, and preserve it in a bottle,
secluded from the light.
  Kermes  mineral may be prepared in a
similar manner, substituting carbonate of
potassa  for carbonate of soda; but the pro-
duct, when the former alkali is used, being
less smooth as a powder and less uniform
in composition, is less esteemed.
  Kermes  mineral  is in  the form  of a
powder of  a dark-brown colour, becoming
lighter by exposure to the  air.  It is com-
pletely decomposed by muriatic acid with
the assistance of  heat, sulphuretted  hy-
drogen  being disengaged.  Gay-Lussac
considers it as a compound of sulphuret of
antimony,  with a small portion  of protox-
ide,  and rests his opinion on  the facts,
that tartaric  acid will extract this oxide
from ordinary kermes, and that the  pure
sulphuret (obtained by precipitating tartar
emetic  by  sulphuretted hydrogen) is of 
ANTIMONY.   (Pharm.)                         41
quite a different colour; but Berzelius
contends, that tartaric acid wdl have this
effect, only when the kermes  contains a
combination ofprotoxide with potassa (hyp-
antimonite of potassa) which  is not es-
sential to its constitution.  The only differ-
ence which Berzelius recognizes to exist
between the true sulphuret and kermes,
is that  the latter always contains a small
portion of  sulphuret of potassium, which,
not being removable by washing, must be
deemed essential to its composition as a
medicine, though not as a chemical com-
pound.
   Golden  Sulphur of Antimony.  This,
strictly speaking, is  not officinal  in the
British or  United States Pharmacopoeias,
the  precipitated sulphuret of these works
being somewhat different  The Paris Co-
dex directs it  to be  prepared  by adding
acetic acid to  the liquor from  which the
kermes has been deposited.  A new pre-
cipitate is thus formed, of a golden-yellow
colour,  which is the  golden sulphur.   It
may be precipitated  also from the same
liquor by means of dilute sulphuric acid.
Its composition is not well made out; but
it may  be gathered from  the remarks of
Berzelius, that he considers it  proportion-
al to antimonious acid ; in other words, a
deutosulphuret of antimony.
   Precipitated  Sulphuret of  Antimony.
This preparation is directed to  be formed,
in the British and United States Pharma-
copoeias, by substantially the  same  pro-
cess, which consists  merely in dissolving
finely powdered sulphuret of antimony in
a boiling solution of caustic potassa, filter-
ing, and precipitating the filtered liquor
by dilute sulphuric acid.  The hot alka-
line  solution of the  sulphuret if  simply
allowed to cool, would deposit the kermes;
and if the cold, clear, liquor were treated
separately with dilute sulphuric acid, the
golden sulphur would be precipitated. But,
in the process above given as that  of the
Pharmacopoeias,  the causes productive of
the  distinct precipitates act simultaneous-
ly; and hence this formula will produce a
product which may be considered as a
mixture of the kermes and golden sul-
phur.  Admitting this explanation of its
mode of formation, it must be viewed  as
an intermediate sulphuret.
   Butter of Antimony.   This is the ses-
quichloride of antimony, and is made, ac-
cording to the French Codex, by distilling
together, finely powdered and well mixed,
18 parts of very pure antimony, and 48 of
corrosive sublimate.   The chlorine com-
bines with the antimony and distils over
as a chloride, while the mercury, revived,
                  4*
is left in the retort. It may also be obtain-
ed by double decomposition, by distilling
a mixture of sulphuret of antimony with
corrosive sublimate.   When procured by
means of corrosive sublimate, it is  per-
fectly free from water.  At common tem-
peratures, it is  a crystalline  mass;  but
when heated it becomes a soft solid,  and
afterwards runs like oil, properties which
suggested its ancient name of butter of
antimony. The same chloride may be ob-
tained, but not entirely exempt from  wa-
ter, by distilling a mixture of one part of
crocus of antimony and two of  decrepi-
tated common  salt, with  one  of concen-
trated sulphuric acid.  The antimonial ox-
ide in the crocus, and the common salt, by
mutual decomposition, form chloride of an-
timony, and soda, the  latter  of which, by
uniting with the sulphuric acid, forms  sul-
phate of soda. It may also be obtained by
dissolving sulphuret of antimony in  con-
centrated muriatic acid.
  Butter of antimony  is sometimes   em-
ployed as a caustic by the surgeons;  but
its chief use is pharmaceutical, namely, to
form the powder of Algaroth, described in
the next paragraph.
  Powder of Algaroth.  This powder, so
called  from Algarotti, the name of an
Italian physician, who first recommended
its use  in medicine, is formed by the ac-
tion  of water on the sesquichloride of an-
timony.  The Dublin process  consists in
first forming the sesquichloride by digest-
ing sulphuret of antimony in muriatic acid,
assisted by a small portion of nitric acid,
and  then pouring it into a large quantity
of water.  The water throws down a white
flocculent precipitate, which is the prepa-
ration in question.
   Powder of Algaroth  is of a white co-
lour. When exposed to heat, it melts,  and
on increasing the heat, with access of air,
it rises in white vapours, condensing on
contiguous cold substances.   The nature
of this powder is a subject of doubt.  Ber-
zelius considers it a submuriate, and states
that when heated in a retort,  a neutral
muriate distils over, and protoxide of an-
timony  remains behind.  That it mainly
consists of protoxide of antimony is proved
by its applicability to the purpose of pre-
paring tartar emetic, for the formation of
which it is  directed in the Dublin  and
United States Pharmacopoeias.  As a me-
dicinal preparation, it has nearly gone  out
of use.
  Diaphoretic Antimony.  This  antimo-
nial  is called the white oxide of antimony
in the French  Codex, and  agreeably to
the directions of that work, is prepared as 
42                         ANTIMONY.  (Pharm.)
 follows.  Equal parts of antimony and ni-
 trate of potassa,  reduced to powder and
 well mixed, are deflagrated in a red-hot
 crucible.   After the deflagration is  over,
 the heat is increased for half an hour; and
 then the matter, having become semifluid,
 is thrown into water.  A powder is preci-
 pitated which is  to be washed repeatedly
 with water, until that liquid conies off
 tasteless.
   In the above process, the antimony be-
 comes oxidized to the  maximum, that is,
 converted into antimonic acid at the ex-
 pense  of the nitric acid of the nitre, and
 in this state unites with the potassa. The
 mass, therefore, after the deflagration is
 over, is the antimoniate of potassa.  The
 product  as thus obtained constitutes the
 unwashed diaphoretic antimony of old phar-
 macy.  By the action of water, as prescribed
 in the Codex formula, much of the potassa,
 and a certain portion of the antimonic acid
 are removed, leaving a white matter, con-
 sisting of antimonic acid united with about
 a fifth of its weight of potassa, which con-
 stitutes the diaphoretic antimony of the
 Codex, but which is commonly known by
 the name of washed diaphoretic antimony.
 If nitric or acetic acid be added to the
 waters  employed  in  washing the  above
 preparation, the potassa present is  neu-
 tralized,  and a white precipitate of hy-
drated  antimonic acid  is  immediately
 thrown down, which was formerly called
 the perlated matter of Kerkringius.
  Diaphoretic antimony is used  in  the
 Codex to form two officinal preparations;
the pulvis Cornachini (Earl of Warwick's
 powder) and the pilula adversus scrofu-
 las.  The former is  a mixture,  in equal
 parts, of scammony, cream of tartar, and
diaphoretic antimony; the latter contains
the same antimonial, associated principally
with scammony and ethiops mineral, (black
sulphuret of mercury).
  Glass of Antimony.  (Vitrified  Sulphu-
retted  Oxide  of Antimony.)   This com-
 pound is prepared from  the sulphuret by
a partial roasting and subsequent fusion,
 conducted in the following manner:—The
sulphuret is reduced  to a coarse  powder,
and  strewed  upon a shallow, unglazed,
 earthen dish,  and then heated gently and
 slowly,  being  continually stirred to pre-
 vent it from running into lumps.   White
 vapours  of sulphurous  acid arise;   and
 when they cease, the heat is cautiously
 increased to reproduce them.  In this man-
 ner,  the roasting  is continued, untd, at a
 red heat, no  more vapours are  found to
 arise.  The matter is then melted  in a
 crucible by means of an intense heat, un-
 til  it assumes  the appearance of melted
 glass, when it is  poured out  on  a heated
 brass plate.  It here congeals  in  a thin
 cake, which  is afterwards broken up into
 pieces of convenient size.
   In this process,  part of the sulphuret is
 decomposed; its sulphur being driven off,
 while the antimony is converted into pro-
 toxide.  The roasted matter, accordingly,
 consists of the portion of sulphuret unde-
 composed, and protoxide of antimony; and
 these,  by uniting  during the fusion, form
 the glass.
   Glass  of antimony is in thin,  hard, and
 brittle pieces,  exhibiting a vitreous frac-
 ture, and having  a  steel-gray colour.
 When well prepared,  a fragment of it
 held between the  eye  and the light, ap-
 pears of a rich orange-red, or garnet co-
 lour.  It  is insoluble in water, but soluble,
 with the  exception of  a few red flocculi,
 in acids and cream of tartar.
   The essential constituents of glass of
 antimony are the protoxide and sulphuret,
 united and vitrified by fusion.  When of
 good  quality, it consists of about eight
 parts of protoxide  to one of sulphuret, and
 is almost entirely soluble in strong muri-
 atic acid. As usually prepared, it contains
 about five per cent, of silica, and three of
 peroxide of iron.   An  excess of silica is
 indicated, when muriatic acid leaves a ge-
 latinous residuum; and iron may be de-
 tected by ferrocyanate of potassa.
   When glass of antimony is  levigated
 and mixed with one-eighth of its weight
 of melted yellow  wax, and  the  mixture
 roasted  over a slow fire, with  constant
 stirring, until it ceases to exhale  vapours,
 a coal-like, pulverizable mass is formed,
 which is the cerated glass of antimony, a
 preparation formerly included in the Edin-
 burgh Pharmacopoeia.
  Crocus of Antimony.  This preparation
 is called in the French  Codex, the  Semi-
 vitrified sulphuretted oxide of antimony.
 It is usually made by  deflagrating, in a
 red-hot crucible, equal weights of sulphu-
 ret of  antimony and nitrate of potassa.
 The nitric acid is decomposed, and  by
 furnishing oxygen  to part of the sulphu-
 ret, converts  its constituents into sulphu-
 ric acid and protoxide of antimony.   The
 sulphuric acid then combines with the po-
 tassa, forming a white crust of sulphate of
 potassa above;  while the protoxide unites
 by fusion with  the undecomposed sulphu-
 ret to constitute the crocus beneath.
  Crocus of antimony is in the form of a
liver-brown, opake, vitrified mass.  When
of bad quality, it is steel-gray.  It consists,
like the glass, of protoxide and sulphuret 
ANTIMONY.   (Pharm.)
43
but united in different proportions, which
are stated by Proust to be three parts of
the former to one of the latter.
   Subsulphate of Antimony.  This salt
was brought  into notice as a pharmaceu-'
tical  preparation of antimony,  by  Mr.
Phillips, of London, who proposed it as
an eligible substance for forming tartar
emetic.   It is prepared by boiling to dry-
ness,  in an iron vessel, powdered metallic
antimony with twice its weight of sulphu-
ric acid, and washing the grayish product
with  water, until the uncombined sulphu-
ric acid  is  separated.   This  substance,
though called a subsulphate, is  essentially
the protoxide of antimony, the quantity of
acid which it contains  being variable in
amount  and  probably not constituting a
definite proportion.
   Tartar Emetic. This important double
salt is the chief of the antimonial prepara-
tions, and as such deserves to be treated of
fully in its pharmaceutical relations. The
principle of  its formation  is  exceedingly
simple, being merely the saturation of the
excess of acid in cream  of tartar with
protoxide of antimony.   The various pro-
cesses, recommended for its formation, all
agree in boiling, in  water, a mixture of
cream of tartar with some form of anti-
monial protoxide, and only differ in the
one selected, and in some minor details of
manipulation.  The  United States Phar-
macopoeia, following the Dublin,  employs
the powder  of Algaroth  (nitro-muriatic
oxide), the London, the glass  of antimo-
ny, and  the Edinburgh, the crocus.  The
French Codex gives two formulte for pre-
paring this  antimonial, the glass being
used  in one,  the subsulphate, agreeably to
Mr. Phillips's  recommendation,  in the
other.  The  proportions usually employed
are equal weights of the antimonial oxide
and cream of tartar,  boiled with from four
to six times their  weight of water  for
about half an hour;  but in the  case of the
nitro-muriatic oxide, this being a purer
oxide than the others, four parts  of it are
sufficient for five of the cream of tartar.
   In judging of the relative  eligibility of
the different forms  of antimonial oxide,
used in  manufacturing tartar  emetic, se-
veral circumstances must be  taken into
view.  The  glass of antimony, though ca-
pable of furnishing  good tartar emetic, is
objectionable on several grounds.  Besides
being liable  to adulteration with glass of
lead,  it  always  contains  about  five per
cent, of silica, and a small portion of per-
oxide of iron.  Even when obtained of
good quality, it requires to be finely levi-
gated ; as otherwise it will unite in part
only with the cream of tartar.  The same
general objections lie also against the cro-
cus.  Rejecting the glass and crocus for the
reasons above stated,  Mr. Phillips pro-
posed  the subsulphate,  which  certainly
furnishes an excellent and cheap material
for forming tartar emetic. M. Henry, how-
ever, an eminent pharmaceutist of Paris,
objects to the subsulphate, as being of va-
riable quality; and, after an elaborate com-
parison of the different processes,  gives a
decided preference to the nitro-muriatic
oxide (powder of Algaroth) of the Dublin
College for preparing this antimonial. The
only objection which has  been urged
against this oxide is its comparative cost,
which is  altogether a minor  considera-
tion, where the  purity of so important a
medicine  as  tartar emetic is concerned.
  In preparing tartar emetic, it is desira-
ble to have a slight  excess of antimonial
oxide,  rather than an excess  of cream  of
tartar;  for in the latter case, the cream
of tartar  may crystallize upon  cooling
with the tartar emetic, and thus render it
impure.   In  all cases,  the  antimonial
should be obtained in well-defined crys-
tals, unmixed with those of cream of tar-
tar, as  the best index of its purity; and
apothecaries  should  purchase it in crys-
tals, and  as  it  is wanted powder it  for
themselves.  The practice of some manu-
facturing  chemists, of boiling the filtered
liquor which contains the tartar emetic to
dryness, whereby it becomes contaminated
with the impurities which, in the crystal-
lizing process, would remain in the mother
waters, is very reprehensible, and should
be entirely laid aside.
  Tartar emetic, called correctly the tar-
trate of antimony and potassa in the Dub-
lin and United States Pharmacopoeias, is a
colourless, inodorous salt, possessing a nau-
seous styptic taste, and crystallizing usual-
ly in rhombic octahedrons. When prepared
by means of the nitro-muriatic oxide, its
crystals have the appearance of tetrahe-
drons.  As it occurs in  the shops, it is in
the form of a white powder, formed by the
pulverization of the crystals.  The  crys-
tals, when exposed  to the air,  effloresce
slightly and become opake. Tartar emetic
is insoluble  in  alcohol,  but dissolves  in
fourteen  times  its  weight of  cold,  and
about  twice  its  weight  of boiling water.
Its aqueous  solution reddens litmus, and
undergoes spontaneous decomposition by
keeping.   According  to Berzelius, the
protoxide is precipitated from the solution
of this salt by sulphuric, nitric, or muri-
atic acid, but not by the  alkalies.  Agree-
ably to Turner, a little pure potassa throws 
44                         ANTIMONY.   (Pharm.)
down the protoxide from a solution of tar-
tar emetic, but takes it up again, if added
in excess. According to the same authori-
ty, the alkaline carbonates throw down
the protoxide also, but much  more com-
pletely. Turner also admits that the min-
eral acids throw down a precipitate; but
instead of considering it with Berzelius,
the protoxide, he  states it  to consist of
cream of tartar and a subsalt of antimony.
It must be recollected, however, that on
trying any of these precipitations, the so-
lution of the antimonial salt must be strong,
and the several precipitants  not added too
freely, otherwise they wUl produce no
effect
   Tartar emetic is precipitated in a very
characteristic manner by sulphuretted hy-
drogen, which throws down an orange-red
precipitate consisting of hydrated sesqui-
sulphuret of antimony.
   When tartar emetic is pure, it should
exhibit its appropriate crystalline  appear-
ance, and be entirely soluble  in distilled
water.  Its solution should not be precipi-
tated by muriate of baryta, oxalate of am-
monia, acidulous nitrate of silver, or acid-
ulous acetate  of lead.   A precipitate by
the first reagent indicates sulphuric acid;
by the second, lime;  by the  third,  muria-
tic acid; and by the  fourth, cream of tar-
tar.   The most usual impurities which it
contains, are uncombined cream of tartar,
tartrate of lime, silica and  iron, and sul-
phate of lime. Cream of tartar is present,
usually either from  its having been used
in excess in preparing the  salt,  or from
fraudulent admixture.  Tartrate  of lime
is derived from the cream of tartar, which
always contains this  impurity, as found in
the shops. It is apt to form on the surface
of the crystals of tartar emetic in crystal-
line  tufts,  which are easily brushed off
Silica and iron  are  liable to be present
when glass of antimony has  been employ-
ed in  preparing the antimonial salt, and
the evaporation has been  carried too far.
Sulphate of lime is sometimes an impuri-
ty, when  tartar emetic has been prepared
by means of the subsulphate.  According
to Serullas, tartar emetic,  as ordinarily
prepared, and all the  other antimonial pre-
parations, usually contain a minute por-
tion  of arsenic,  derived  from the native
sulphuret of antimony, which almost al-
ways contains this dangerous  metal.  Its
presence in tartar emetic may be detected
by exposing the salt  to the  action of the
blowpipe, when the peculiar odour of the
arsenic will be perceived.  This dangerous
impurity, however, is not present in well-
crystallized tartar emetic, a fact, which
should form  a strong additional  motive
with the apothecary, always to purchase
this antimonial in crystals.
  Besides being decomposed by the min-
eral  acids, the alkalies whether pure or
carbonated,  sulphuretted  hydrogen,  and
hydrosulphates, the  same  effect  is  pro-
duced  by many other  substances.  Thus,
it is decomposed by some of the metals
and their oxides, by lime-water and muri-
ate of lime, and by the acetate and  sub-
acetate of lead.  This antimonial salt is
also affected by common water when hold-
ing carbonate  of lime  in solution, but not
when containing muriates, sulphate of lime,
or extractive matter.  Hence it is necessary
to dissolve it in distilled water, when the
pure effects of the medicine are designed
to be produced.  Other substances which
decompose tartar emetic, are the decoction
of tamarinds,  lemonade, whey, and gene-
rally all  bitter  and astringent vegetables,
such as Peruvian bark, rhubarb, galls, ca-
techu, &c. Of these different substances,
some precipitate the antimonial oxide, and
others produce new salts with it either
soluble or nearly insoluble; but  it by no
means follows that they render the tartar
emetic inert.   On the contrary, the ordi-
nary effects of the medicine are produced,
though by the  agency of the new combina-
tions formed.  Some doubt, however,  may
be entertained whether  this remark will
apply to the effects of the bitter  and as-
tringent vegetable medicines, which  owe
their power of decomposing tartar emetic
to the  presence of tannin, which forms an
insoluble compound with the oxide of an-
timony.  Nevertheless, Laennec  has re-
marked  that  though cinchona and infu-
sions of other vegetables precipitate tar-
tar emetic, still the new compounds form-
ed have  the same  properties as those of
the tartar emetic itself.  It is  difficult to
believe this statement without some quali-
fication ; as the evidence is very strong in
proof of the influence of bark and other
astringent vegetables,  in mitigating the
effects of an over-dose of tartar  emetic.
The truth probably is that  the tannate of
antimony, produced  by these vegetables,
is not  inert, though by no means so active
as the undecomposed salt; and that  it is
capable  of producing similar effects with
tartar  emetic,  provided it  be given  in a
sufficient dose.
  Tartar emetic enters into but three offi-
cinal preparations, contained in the British
and United States Pharmacopoeias. These
are  antimonial wine, tartar  emetic oint-
ment  and Coxe's hive syrup (Mel Scillffl
Compositum. Ph. U. S.). 
ANTIMONY.   (Pharm.)                         45
  Antimonial Wine is made by dissolving
tartar emetic,  in  the proportion of two
grains to the fluidounce, in Teneriffe or
Sherry wine, or in a mixture  consisting
of four-fifths water, and one-fifth rectified
spirit  The Edinburgh and United States
Pharmacopoeias use wine as the menstru-
um; the London and Dublin, water and
spirit in the proportion above mentioned;
but while the menstruum thus differs, the
strength of the preparation, according to
the different formulae, is virtually the same.
To make this preparation of good quality,
the wine should be sound, and free from
astringent principles, and the tartar eme-
tic crystallized.   Antimonial  wine pro-
duces precisely the same effects on  the
system as tartar emetic;  yet  its use is
convenient by affording a ready means of
administering this antimonial in minute
doses.
   Tartar  Emetic Ointment is made, ac-
cording to the Dublin formula, by rubbing
up a drachm of very finely powdered  tar-
tar emetic with an ounce of lard.  It is
not ordered by the other British Colleges,
nor in the United States Pharmacopoeia.
This ointment, however, is generally made
of twice the strength  directed by the Dub-
lin College.   That recommended by  the
late Dr. Jenner  consisted of spermaceti
ointment nine drachms, tartar emetic  two
drachms, white sugar a drachm, cinnabar
 five grains, well rubbed up together. The
 object of the sugar,  according to Dr. Pa-
 ris,  is to prevent the  ointment from be-
 coming rancid; cf the cinnabar to give it
 colour, in order to prevent its being mis-
taken for simple ointment, which, without
this addition, it resembles in appearance.
 The best unctuous matter which can be em-
ployed in making the ointment is lard, when
the preparation is to  be  used in frictions;
but when bound on a part spread on linen,
it requires to have more consistence, and
must be made of simple cerate, or sperma-
ceti ointment  In all  cases,  the  tartar
emetic should be reduced to an impalpa-
ble powder, and thoroughly incorporated
with the unctuous vehicle, which must be
free from watery particles, as these have
the effect of dissolving the tartar emetic,
and of subsiding with it in solution. The
therapeutic effects of this preparation wdl
be noticed under a subsequent head.
   Hive Syrup is a preparation having ho-
ney for  its basis,  and embracing the vir-
tues  of seneka, squill, and tartar emetic,
of which  latter it contains a grain to the
fluidounce.  (See Hive Syrup.)
   Tartar emetic, adopting the results of
Wallquist, may be  considered to consist
of two equivalents of tartaric acid 66 x
2 = 132,  two of protoxide  of antimony
76.6 X 2 = 153.2, one of potassa 43, and
two of water 9 X 2 = 18; total 351.2.
  Antimonial Powder.  This preparation
is usually made by roasting, in  a shallow
iron pot heated to redness, a  mixture, con-
stantly stirred, of equal parts of sulphuret
of antimony in coarse powder, and harts-
horn shavings, until it becomes of an ash-
gray colour.   By this treatment, the sul-
phur of the sulphuret is expelled, and  the
antimony oxidized; while the hartshorn,
which is  of the nature of bone, has  the
greater part  of  its  animal matter con-
sumed, and is  reduced nearly to  the state
of phosphate of lime (bone-earth). The
matter obtained by the roasting is reduced
to powder, and put into a coated crucible,
over which another is  luted, with a hole
in the bottom. It is then  heated  to white-
ness, and kept at that temperature  for two
hours.  The matter found in the crucible,
after being finely pulverized, is  the anti-
monial powder.   By the  calcination at  a
white heat, the remainder of the  animal
matter of the horn is  dissipated;  so that
nothing remains but the phosphate of lime
mixed with oxidized antimony.   The  de-
gree  of oxidation which  the antimony at-
tains, when the above process (the Edin-
burgh)  is followed, is probably,  from  the
white heat employed, that  of deutoxide
(antimonious acid);  but it is certain that
in different samples of antimonial powder,
as found in the shops, a little protoxide  is
also usually present.  This fact,  as well
as the variable action of antimonial pow-
der on the system, warrants the statement
that  it contains  antimony  in a state of
oxidation not uniform, associated with the
phosphate of lime. In preparing this pow-
der, the London and Dublin Colleges  also
employ a white  heat;  but these Colleges
use a double proportion of hartshorn shav-
ings.  The use of the larger proportion of
shavings will  undoubtedly form  a  weaker
preparation, but is justified on the ground
of preventing the vitrification of a part of
the antimony. The late Dr.  Duncan, how-
ever, was of opinion,  that  the  medicine
did  not correspond  so  nearly  with  Dr.
James's powder, as analyzed by Dr. Pear-
son,  when the  larger proportion of the
shavings was  employed.   He was on that
account in favour of the Edinburgh pro-
portions,  which  may be  the more relied
on,  as they  are those   adopted  in  the
French Codex.
   Antimonial powder has a  dull-white co-
lour,  is tasteless and inodorous, and inso-
luble in water. It is only partially soluble 
   46                        ANTIMONY.

   in acids; the phosphate of lime, and any
   protoxide of antimony being dissolved, and
   a variable amount of antimonious acid left
   behind.   Its activity as  a medicine de-
   pends upon the proportion  of protoxide
   present which  may be judged of by dis-
   solving the preparation in muriatic acid,
   and dropping the solution obtained in wa-
   ter, whereupon the protoxide will be pre-
   cipitated.   Its  composition  varies  very
   much,  as already  stated.  Mr. Phillips
   found two specimens, on analysis, to con-
   tain  severally 35 and 38 per cent of oxi-
   dized antimony; and Mr. Brande detect-
   ed in one specimen, 5 per cent of protox-
   ide.  Now the  genuine James's powder,
   as analyzed both by Dr. Pearson and Mr.
   Phillips, contained from 56 to 57 per
   cent of oxidized antimony.   A portion of
   this powder, derived from the heirs of Dr.
   James, was found by Berzelius to contain
   nearly two-thirds antimonious acid (deu-
   toxide), and one-third phosphate of lime,
   with scarcely one per cent of antimonite
   of lime  soluble in water.   Phillips and
   Brande speak  of  the antimony as being
   in the state of peroxide (antimonic acid);
   but it certainly must be in the state of
   deutoxide (antimonious acid), as stated by
   Berzelius,  if the materials for forming
•  the powder are  exposed to a white heat as
   directed by the British Colleges.  From
   the above facts it must be evident that the
   antimonial powder of the shops is a pre-
   paration of variable  Composition; and it
   will be readily  admitted that the Medical
   Convention for revising our National Phar-
   macopoeia acted wisely  in expunging it
   from that work.
    § III. Effects  on the System, and The-
   rapeutical Applications.  The prepara-
   tions of  antimony were introduced  into
   medicine towards the close of the fifteenth
   century; and the  first treatise of impor-
   tance written on them was the Currus Tri-
   umphalis Antimonii of Basil Valentine.
   Their introduction gave rise to a keen
   controversy between the Galenists  who
   denounced, and the  chemical physicians
   who advocated, their use; and the former
   carried their opposition to such an extent,
   as to prevail on the Supreme Council of
   Paris to issue an edict in 1566 forbidding
   their use.  By a revolution of opinion, not
   uncommon in similar cases, antimony was
   admitted, by the Paris faculty, into  the
   Antidotarium, published in 1637.  It was
   still, however,  strenuously opposed by a
   number of physicians of Paris, and espe-
   cially by Guy Patin, who published a long
   list of unsuccessful cases, treated by anti-
   mony, under  the title of Martyrologe de
(Therapeut.)

TAntimoine. Finally, in 1666 the Parisian
faculty met to decide the dispute, and de-
termined in favour of the antimonial re-
medies, a verdict confirmed soon after by
a decree of the Parliament of Paris, au-
thorizing their use.  The grounds of ob-
jection to antimony by its opponents were
its  poisonous  qualities;  grounds which
would be taken as proof, in modern times,
of its activity, and,  therefore,  remediate
capabilities.
  The antimonial preparations impress a
special  modification  on  the vital move-
ments, which  varies  with their dose and
manner of administration, and  the condi-
tion of the system to which they are ap-
plied.  In minute doses, they produce, in
the mode of vitality of parts,  those gra-
dual changes,  which, for want of a better
term, are called alterative; and as their
quantity is gradually increased, they are
capable of occasioning successively a seda-
tive, diaphoretic, cathartic, emetic, contro-
stimulant and corrosive  effect  Where
effects so diversified are produced by the
same class of remedies, it is not easy to
reduce  their  modus operandi to general
principles.  It may be admitted, however,
that the antimonials have the  power of
producing a disturbance  in the vital ac-
tions, whether healthy or diseased; and
that this disturbance  is  manifested thus
variously, not  only according to the dose
and the condition of the  system, but also
according to  the  degree  of solubility of
the particular  preparation, its power as a
local irritant, the extent of its  dilution if
soluble, and the amount in which it may
be  absorbed.  If the antimonial be given
in a minute dose, especially if soluble, and
exhibited very much diluted, its action is
that of an  alterative.  If administered in
somewhat larger doses, it produces, with-
out  creating  nausea,  a  sedative  effect
throughout the whole system,  but espe-
cially upon the heart  and arteries. The re-
medy,   in  a  somewhat   increased dose,
causes nausea, which may be  viewed as
the first indication of a vital resistance, on
the part of the stomach, to the entrance of
a noxious agent by way of absorption, into
the blood.  At the same time, part of the
antimonial may still be  absorbed, with,
perhaps, increased sedative effects, evinced
more particularly by relaxation of the ex-
halants of the skin.  If the antimonial be
continued in nauseating doses,  it may not
act powerfully enough to produce emesis;
and yet by stimulating the  absorbents of
the stomach and bowels which now refuse
to  let  it pass by absorption,  may cause
these to pour out their contents, and thus 
ANTIMONY.  (Therapeut.)
47
produce a cathartic effect  A larger dose
of the  antimonial causes vomiting, proba-
bly by  still further arousing  the vital re-
sistance of the stomach.  Finally, if given
in a poisonous dose, especially if the pre-
paration be chemically  acrid, or soluble
and undilute, it may be conceived to para-
lyze the vital actions of the stomach, and,
consequently, to be neither absorbed, nor
expelled. At the  same time, the nervous
system would receive so great a shock, as
to cause a general depression of the vi-
tal powers, similar in nature  to that pro-
duced  by small doses of antimony, but far
greater in degree, and attended with le-
sion of the  stomach.
   The view here taken of the modus ope-
randi of antimonials in producing vomit-
ing may be objected to on the ground, that
wherever applied  in c.  proper dose they
have a strong tendency to excite emesis.
Thus when injected into the  rectum or
veins, or applied to any surface by which
they may be  sufficiently absorbed,  they
produce vomiting,  just as when they are
brought in contact with the stomach; a fact
which  shows that the emesis is not ex-
clusively the effect of the local irritation
on the mucous surface of the stomach.
   The antimonials as a class have gene-
rally been characterized as irritants; but
in a practical point of view, they should
not all be deemed such.  In one  sense,
every  substance  that  can make an  im-
pression on the system, may be called an
irritant; but taking the word in its ordi-
nary acceptation as a pathological term, it
includes every agent capable of producing
inflammation or increased action in a part
Admitting this definition of an irritant
minute or small doses of antimony, when
they excite neither nausea nor uneasiness
of stomach, cannot be classed as  such.
On the  other hand, when the metal  is
given  in larger doses, especially if one
of the soluble preparations is employed,
which  are uniformly most active, its irri-
tant effects will be manifested.  The so-
lubility or non-solubility of the prepara-
tion, and its degree of dilution if soluble,
are circumstances which must be  taken
into the account.   If insoluble  in water,
its irritating effects, cseteris  paribus, wili
be less or longer  in being developed ; if
soluble, the same dose  may act as an irri-
tant when given in substance, and as a se-
dative  when largely diluted.  Thus half a
grain of tartar emetic,  if given in pill,
may, by coming in contact with the sto-
mach, in its solid state, act as an irritant;
while if given at once dissolved in a pint
of water,  it would have no such effect
Many analogies support this view of the
influence of the dose and concentration of
a remedy, in determining its physiological
action.  The mineral acids, concentrated,
are corrosive poisons; largely diluted, refri-
gerant.  Again, sugar of lead in substance,
or in concentrated solution,  is irritant; and
in very weak  solution, as lead-water, an
abater of inflammation and  irritation.
   Abundant proof  certainly exists, that
the antimonials are capable of acting as
irritants; but this by no means shows that
they necessarily must be so in every dose,
and  under every form of administration.
Thus, Rayer  reports a fatal case of apo-
plexy,  in which, during the five days the
patient was sick, he took forty grains of
tartar emetic,  without producing nausea
or vomiting.   Upon opening the body, the
alimentary canal exhibited changes,  mani-
festly dependent on the action of the an-
timonial.  The stomach was very red and
inflamed, and  filled with bile and mucosi-
ties.   The inflammation appeared  to be
confined to the mucous membrane of this
viscus,  upon which were perceived irre-
gular spots of  a livid red colour, on a vio-
laceous base.   Here an antimonial proved
to be irritant,  having been  given  in large
doses without  the stomach  responding to
the impression in the usual  way, in conse-
quence  of the lesion of the nervous sys-
tem, implied by the apoplectic state; but
it would be a vicious use of reason to con-
clude from this or similar facts, that  tartar
emetic, however exhibited, as in half or
quarter grain  doses daily  in  a quart of
water, would prove irritant  On the con-
trary,  it may  be conceived  that minute
doses of a substance, irritant in medium
or large doses, may act as an abater of ir-
ritation, by creating a new  impression, in-
consistent with the preceding one, in the
irritated part.    Holding these views, we
conceive that  the positions taken in the
following quotation are altogether too gen-
eral  to be admitted as precise.  " All the
preparations of antimony, without excep-
tion, possess an irritant property.   Thus
tartar emetic applied to the skin, or to the
mucous membrane of the eye, nose, mouth,
or genitals, excites a severe and peculiar
inflammation.  Taken into the alimentary
canal,  it always causes an inflammation
more or less intense, modified by the pre-
vious condition of the canal, and by some
other circumstances difficult and often im-
possible to appreciate."
   The error of supposing the antimonials
to be necessarily and universally irritant, 
49                       ANTIMONY.

is the more to be regretted,  as it has
a  tendency to cause the practitioner to
overlook, if not  to deny,  their sedative
or antiphlogistic effect.   This effect may
be considered as belonging to small doses;
and  to such doses because they are more
easily absorbed, and, by their presence in
the  circulating fluids,  independently of
any  necessary connexion with evacuation,
lessen the vital actions  whether healthy
or diseased, without producing  those per-
turbations which  larger  doses would cre-
ate.   But explain it as we may, still it is
certain that antimony, properly adminis-
tered, has  a depressing influence upon
nearly all the vital phenomena, and con-
sequently may become proper in diseases
characterized by excessive action. In most
fevers, therefore, and in all inflammations,
it may prove useful as  an antiphlogistic
remedy.  Gastritis even  is not an excep-
tion  ; for the principles  here laid down,
call  only for the constitutional  effects of
the  remedy; and it by no means follows
that ui obtaining these effects,  it must be
brought in contact with  the  suffering or-
gan.  On the contrary, some other chan-
nel  for its introduction  would be proper.
In fevers, the general effect  of the anti-
monials is to reduce the force and  fre-
quency of the pulse, and at the  same time
to lessen the rapidity of the  respirations,
and  the heat of the surface.   In this class
of diseases, the stomach is the seat of more
or less irritation, but it by no means follows
from this fact that antimonials must be
abandoned  in their treatment.   It is un-
questionable, that antimony was formerly
too freely given in fevers; for where nausea
and gastric distress exist as they often do,
it  seems hardly justifiable to  aggravate
these local conditions, in order  to gain its
depressing influence on the heart and ar-
teries.  On the other hand,  however, it
may  be admitted  that the prevalence  of
the  gastric pathology of fever has  led
some practitioners into  the opposite ex-
treme, and caused them  to proscribe anti-
monials in that class of diseases altoge-
ther. Upon the whole, it may be averred,
that  the antimonials constitute a valuable
resource  in the treatment of febrile dis-
eases, and  may be so managed, in many
instances, as  to  do  incomparably  more
good by their depressing influence on the
actions of the general system, than harm
by any local irritation, supposing such ne-
cessarily to take place.
  The general antifebrile  and antiphlo-
gistic action of the  antimonials, when
given in small doses, having been suffi-
ciently set forth in the preceding remarks,
 (Therapeut.)

 it may now be proper to descend into de-
 tails, and to speak of the more prominent
 effects of these preparations, on the differ-
 ent  systems, functions, and tissues  of the
 body.
   Circulatory  System.   MM. Recamier
 and  Trousseau, who appear to  have ac-
 curately studied  the effects  of antimony
 on this  system,  by means of observa-
 tions made on a great number of patients
 at the Hdtel-Dieu, found, by its use, that
 the  pulse  became  weak  and  slow, and
 that the pulsations of the  heart, explored
 by the stethoscope, were in harmony with
 the pulse.  They observed, in some cases,
 the  pulsations  to  descend in three days
 from seventy-two to forty-four in a minute,
 and to remain for a long time at that num-
 ber.   Ordinarily the pulse was reduced in
 force in  a  very marked manner; but the
 number of pulsations did not descend low-
 er than a fifth or a fourth.  They observed
 sometimes  that the  pulse  became exces-
 sively irregular,  without  losing its fre-
 quency ;  and this irregularity lasted some-
 times during the whole period of the me-
 dication, but more  generally it preceded
 and announced the diminution of the fre-
 quency of the pulse.
   Cutaneous Exhalants.  A very common
 effect of the antimonials, and generally a
 concomitant one with that on the circula-
 tion, is an impression made  on the cuta-
 neous exhalants, in consequence of which
 the  insensible  perspiration is  increased,
 and  the  skin, from  being harsh and dry,
 becomes soft and moist  This effect  takes
 place more invariably when nausea has
 been produced, and perhaps to  a greater
 extent; but this sensation  is by no means
 essential to its production.  On the con-
 trary, the antifebrile and diaphoretic  influ-
 ence of antimony  may be produced in a
 most decided manner,  without  creating
 the least nausea.  While this is  admitted,
 it by no means follows, as  is  supposed by
 some writers, that the occurrence of nau-
 sea is unfavourable to obtaining the spe-
 cific antifebrile effects of antimony.
  Respiration.  Recamier and Trousseau
 found that the number of respirations was
 diminished to such an extent as sometimes
 to be reduced  from  sixteen, twenty, or
 twenty-four, to six in a minute.   The pa-
 tients, breathing with this  extreme  slow-
 ness, did not experience any difficulty in
 respiration; on the  contrary, they  gave
 evidence by their  countenance, and by
their declarations, that  they felt better.
The effects of antimony on the circulation
and  respiration were often found by the
above-mentioned writers to continue  for 
ANTIMONY.  (Therapeut.)
49
several days  after the medicine was dis-
continued.
  Pulmonary Mucous  Tissue.   Minute
doses of the antimonials frequently cause
the pulmonary exhalants to discharge an
increased quantity of matter, and of a more
liquid kind, and hence act advantageously
in many diseases as an expectorant The
theory of their operation is not important;
but it may be supposed to be by lessening
action in the pulmonary mucous vessels,
which, in the cases benefited by the  re-
medy, are  too highly  excited to secrete
freely. Where the action of these vessels
is too weak, as in the last stages of pul-
monary consumption,  antimonials, as ex-
pectorants, are contra-indicated, and car-
bonate of ammonia, by its stimulating ef-
fects, may prove useful.
   Urinary  Secretion.   According to Re-
camier and Trousseau, the use  of anti-
monials almost always augments the se-
cretion of the urine.  This effect has not
been generally mentioned by writers; and
when it does take place, it will probably
be in cases,  in which the diaphoretic ef-
fect of the remedy is prevented by the ap-
plication of cold to the surface, or by some
other cause.
  Lymphatic System.  That antimony is
capable, under peculiar circumstances, of
throwing the brunt of its action on the
lymphatics,  is proved by  the  fact of its
having, in a few rare  instances, produced
ptyalism.  The late Dr. James stated that
he had seen six instances of this kind; but
in them, the teeth were not loosened, nor
was the  breath  rendered offensive as in
mercurial salivation. That there is a slight
affinity between antimony and the salivary
glands is made  probable by the fact that
Die  system is  rendered  more  suscepti-
ble of the influence of mercury,  by com-
bining it  with  antimonial  preparations.
Dr. Eberle plausibly explains this fact
by referring it to the  power which nau-
seating doses of antimony possess of fa-
vouring an afflux to the salivary glands.
This idea is ridiculed by Dr. Paris, in a note
to his Pharmacologia,  which has no other
merit than that of being witty.  He says
that if Dr. Eberle's explanation were cor-
rect no one need despair of influencing his
patient by mercury; since nothing more
would be necessary than to condemn him
to meagre fare,  and then to tantalize him
with the sight or smell of a savoury dish!
  The diversified effects produced by the
antimonials, whether alterative, sedative,
cathartic, emetic, &c, so far as dependent
on the dose,  have been sufficiently dwelt
upon in the foregoing remarks. But there
  VOL. II.          5
are a number of other circumstances which
modify their operation; such as the par-
ticular antimonial employed, the suscepti-
bility of the alimentary canal, the duration
of the  medication, the diet and regimen
directed, and the age and  sex of the pa-
tient These will next claim our attention.
   Particular Antimonial. The antimonial
preparations differ very much in activity,
from tartar emetic, the most active,  down
to antimonious acid (deutoxide) which is
nearly inert.   The order of their activity
in the descending scale  is 1. tartar eme-
tic; 2. perfectly pure and  porphyrized
metallic  antimony;  3.  unwashed diapho-
retic antimony;  4. kermes mineral; 5.
powder of Algaroth;  6.  washed  diapho-
retic antimony;  7. pure protoxide; 8. an-
timonious acid.  Trousseau places anti-
monic acid (peroxide) last, as the least ac-
tive of all the  preparations; but this is
probably a mistake, arising from the  cir-
cumstance that the  real  antimonious acid
has  generally been called, in medical
works, the peroxide.  It admits of much
doubt, indeed, whether the therapeutic ef-
fects of the pure  peroxide have as yet been
tried. Of the above preparations, the more
active, such as tartar emetic and porphy-
rized antimony, are  capable of producing,
by graduating the dose, all the effects of the
antimonials, from the most active vomiting
and purging, to their almost imperceptible
alterative effects; while the less active
preparations can be viewed as appropriate
only for creating the sedative operation of
the antimonials.   Thus to produce an ef-
fect equivalent to that of half a grain of
tartar emetic, it would be necessary to use
five or ten grains of kermes mineral, from
half a drachm to a drachm of the protox-
ide, and from two drachms to half an ounce
of antimonious acid.
   According to Trousseau, the choice of
the  antimonial  is of the highest impor-
tance to the judicious employment of the
antimonial preparations.  A good summary
of his views on  this point is contained in
the following quotation.  " Antimony acts
most frequently, not by  an inflammation
which it excites in the mucous membrane
of the intestine, not by modifications pro-
duced  in the  secretions, but solely  by an
organic modification, the nature of which
is unknown, and which is equally spe-
cial with  that  produced  by  mercury,
arsenic,' opium, the solanese, the strichnos,
&c. It, accordingly, follows, that when-
ever it is absorbed, it produces its effects,
whatever may be the form under which it
is employed, in the same  manner that opi-
um produces narcotism, sweats, &c. under 
50                        ANTIMONY.

every form in which it may be taken. The
problem to be solved is, therefore, this: to
cause as much antimony to be  absorbed
as we can, and at the same time to cause
the slightest possible local lesions; and
the administration of the oxides of anti-
mony fulfil the conditions of the problem.
I do not hesitate to declare  that if the Ra-
sorian method  has met with so many op-
ponents, its  disfavour is  to be attributed,
less to the inutility and danger of antimo-
ny, than to the bad choice of the antimo-
nial compound; and if, on the one hand, I
admit  that tartar emetic  in large doses is
often  a dangerous agent I assert on  the
other, resting my assertion on experience,
that the  oxides of antimony have, in the
cases referred  to, all the advantages of
tartar emetic, without its inconvenience."
(Trousseau. Art. Antimony, in Diet, de
Med.  III. 225.)
  The views of Trousseau expressed in
the above extract may be admitted to be
correct so far as they assert that the con-
stitutional effects of antimony are obtain-
ed, in proportion as the remedy is absorb-
ed without producing local lesions.  But
it by no means follows, that the  mode of
using antimony by  Rasori, (tartar eme-
tic in  large doses,) is a case in point; for
though the  tartar emetic,  when used in
these  doses,  may, to a certain extent be
absorbed,  it probably acts on a  principle
totally different from absorption.
  Susceptibility of the Alimentary Canal.
When inflammation exists  in the mucous
membrane of the alimentary canal, doses
of antimonials, which under other circum-
stances would be absorbed either in whole
or in part, and  produce an antiphlogistic
effect  on  the general system, will  now
exasperate the  inflammation, fail to be
absorbed,  and  consequently  produce  re-
peated vomitings and purgings.   Trous-
seau declares that he has seen  phthisical
patients perish  rapidly from the adminis-
tration of antimonials, which acted by ag-
gravating the tuberculous inflammation of
the intestines.  It is certain that antimo-
nials must be used with great caution, and
their  effects closely watched, when  the
state  of the alimentary canal is a matter
of doubt; but it is going  too far to assert
as Trousseau has done, that antimony can
be  given  only in cases in which the  ali-
mentary  mucous membrane is healthy.
The adoption of such a rule  would exclude
antimonial remedies in many inflammatory
diseases, in  which this membrane is to a
certain extent affected.   The proper rule,
in such cases, lies between the extremes;
—neither to abandon the  antimonials alto-
(Therapeut.)

gether,  nor  yet  to use  them with an un-
sparing  hand.  When the irritation is not
intense, antimony may be used in minute
doses, with the well-founded expectation
of its being  absorbed, so as to produce its
antiphlogistic influence; while its local ac-
tion would be inappreciable, or if slightly
irritant less injurious as such, than bene-
ficial by controlling general action.
  Trousseau  appears to admit in prac-
tice, the principles here insisted upon, and
perhaps to push them further than we do.
Thus he remarks that it must not be sup-
posed that the  existence of an abundant
acute diarrhoea, and of vomiting, will al-
ways contra-indicate the use  of antimoni-
als, and appeals to the results of Laennec
to show that such a condition of the abdo-
minal viscera is often relieved by a large
dose of tartar emetic or kermes.  But it
may be asked,  is the mucous  membrane
healthy in such cases, as Trousseau says
it must  be to justify the use  of antimoni-
als 1  We admit however, that the prac-
tice might be useful in diarrhoeas and vo-
mitings of  a certain kind, for example,
when they are bilious; for here the reme-
dy  would speedily remove  the offensive
matters, more irritant to the system than
the remedy itself.  StUl even in the case
supposed,  we  should prefer  ipecacuanha
as an evacuant, unless the condition of the
system  was  such as to call for a vigorous
agitation  of the abdominal viscera, parti-
cularly  the liver.
  In deciding on the extent to which an-
timonials  may be used when the alimenta-
ry canal  is  more  or less implicated, the
practitioner  should consider whether this
part is  primarily or secondarily affected.
If primarily affected,  he should abstain
from  the  use  of these  remedies, or try
them with the greatest caution; but if, on
the other  hand, the affection of the ali-
mentary canal is secondary to an inflam-
matory affection of some other part, anti-
monials as a general rule may be employ-
ed.  Thus in acute pneumonia, antimony
may be  often given with great advantage,
even though the stomach and bowels are
the seat  of a secondary  affection;  but
when the contrary takes place, and  in-
flammation  of  the lungs supervenes on
bowel disease, the antimonials aggravate
the primary affection, without benefiting
proportionably the secondary one.  Thus
Trousseau  declares that he has often seen
Laennec,  for want of making these dis-
tinctions,  produce  a fatal aggravation of
that form of intestinal disease, called  do-
thinentery, when it happened to be com-
plicated with thoracic disease. 
                          ANTIMONY.

  Duration of the Medication.  It is a
fact well ascertained by repeated observa-
tion, that the violent effects, such as vo-
miting, purging,  colicky pains, &c, pro-
duced by the soluble preparations of anti-
mony when first  administered, generally
subside after a shorter or longer interval,
extending  usually from twelve hours to
three days; the system becoming in  the
mean  time  habituated to the remedy,
which no longer produces the above-men-
tioned effects, but a depressing influence
on  the vital movements.  This peculiar
condition of the  system, of bearing  the
remedy  without   its producing  marked
perturbations  of  the  system,  is called
by  Rasori,  the  condition of tolerance
(see this word);  and when it is  brought
about tolerance is said to be established.
To produce this tolerance of the antimo-
nials in certain  phlegmasial diseases is,
according to this  Italian physician, and to
others who enter more or less  into his
views, of the utmost importance; and the
physicians of this school seek to induce it
by all the means  in their power.  Accord-
ing to Trousseau, its immediate produc-
tion is  almost always the consequence of
using insoluble, instead of the soluble, an-
timonial preparations; as they enter the
circulation readdy, without producing, ex-
cept in rare cases, either vomiting or di-
arrhoea.   The results of this practice re-
quire  to  be  amply confirmed, before it
would be proper to rely on  them implicit-
ly; but should they prove well founded,
they will enable  the practitioner to avail
himself fully of the antiphlogistic effects
of antimony in large doses, without  pro-
ducing those local lesions which so  fre-
quently result from the  use of tartar eme-
tic  and the other soluble preparations of
this metal.
  The  duration  of the tolerance, after
having been established, is  very variable;
and  it becomes important  to know what
circumstances may cut it short, or render
it less liable to be terminated. When the
tolerance is established with difficulty, it
generally has but a  short duration; but
when readily induced, it lasts four, eight
and  even fifteen  days when the  soluble
preparations are employed,  and almost in-
definitely,  when  the insoluble ones  are
resorted to.
  It becomes necessary, however, what-
ever may be the duration of the tolerance,
to omit the antimonials as soon as it ceases.
To attempt to continue  them afterwards,
would, according toTROussEAU, give rise to
the danger of producing lesions of the  sto-
mach.  Accordingly, the occurrence of vo-
 (Therapeut.)                        51

miting and purging, after  tolerance has
been established, shows that it is at an
end, and that the antimony must be dis-
continued.  On  this point the views of
Rayer, the writer of the article Antimony
in the Diet, de Med. et de Chir. Pratique,
are diametrically opposite.   Thus he re-
marks  that he has never known the good
effects of tartar emetic to be more marked
than when, on the access of peripneumo-
nies, it has procured abundant evacuations
upwards  and downwards;  a fact which
tends to prove, according to him, that, con-
trary to the opinion of Rasori, the deriva-
tive action and depletive revulsion of tar-
tar emetic on the stomach and bowels, are
prominent elements in its curative effects.
Dance and Chomel appear to be of the
same opinion; for, according to them, anti-
mony has no special mode of action. When
it purges or vomits, it acts precisely like
purges and emetics in general; and when
it is perfectly tolerated, it is without ef-
fect.   We can  barely conceive of some
cases of inflammations, other than of the
alimentary canal,  in which the evacuant
qualities of the  antimonials could replace
advantageously  their  antiphlogistic  ef-
fects consequent upon tolerance; but as
a general rule, the influence of the reme-
dy obtained by tolerance is much more to
be relied on.
   Supposing  the establishment of the to-
lerance of antimonials to be important in
the treatment of certain inflammations; it
becomes an interesting question to deter-
mine, how this state can be most certainly
 induced, or how reproduced, after it has
ceased. Laennec was in the habit of pro-
moting the tolerance of tartar emetic by
associating it with opium,  and of lessen-
ing its nauseating effects by the  addition
of aromatics.  Trousseau objects to the
use  of opium for  this purpose, except at
the very beginning, on the two grounds
that opium injures the antiphlogistic ef-
fects of antimony, and has a tendency for
a time to mask intestinal  lesions, which
afterwards manifest themselves with great
force.
   It sometimes happens, when tartar eme-
tic has been used for several  days, that
the  patient experiences a sensation of
tension in the throat, and over the lining
membrane of the mouth, accompanied by
some pain and  a metallic taste.  This
condition  of  the mouth and  throat  has
been  assimilated  to that  produced by
mercury, and has been expressed by the
phrase, antimonial saturation.  We agree,
however,  with  Trousseau, in believing
that the condition referred to is no indica- 
52                        ANTIMONY.  (Therapeut.)
 tion of a constitutional impression from
 antimony, but is entirely local.
   Diet and Regimen employed.   As in
 the  case of other remedies, the diet em-
 ployed during the administration of anti-
 mony has an important influence on its ef-
 fects.  As a general rule, the more severe
 the diet, the more easy the  establishment
 of  tolerance, and the more  prominent
 the  constitutional effects,   if aliment be
 incautiously given, its digestion is arrest-
 ed, and the remedy, assisted by the dis-
 tension caused by the food, gives rise to
 vomiting, whereby the antimony is dis-
 charged. We cannot admit, however, the
 accuracy  of Trousseau's  opinion, that
 " the local irritant action of the antimoni-
 als is  so much the stronger, as the quan-
 tity  of aliments  is more  considerable."
 Vomiting,   under  these  circumstances,
 more readily takes place;  but this does
 not prove a greater local  irritant action
 on the part  of the antimony, since its ef-
 fect is assisted by extraneous causes.  On
 the contrary, the remedy would prove less
 irritating from being mixed up with the ali-
 mentary matters, and from being quickly
 discharged; while its constitutional effects
 would  be defeated by its non-absorption.
  Certain aliments, 6uch as wine, the acid
fruits,  and drinks made from  acerb and
acid fruits, augment in a remarkable man-
ner the activity of the insoluble prepara-
tions of antimony.  They act by the tar-
taric or citric  acid which  they contain,
and which, by forming a soluble salt with
the antimonial, renders it violently emetic.
In the case of so soluble a salt as tartar
emetic, it may be doubted whether the
above-mentioned substances have any pow-
er of increasing its activity.
  Age and  Sex  of the Patient.   It  has
been established by observation, that vo-
miting and diarrhoea are more  easily ex-
cited by antimonials in children and fe-
males, than  in male  adults; and at  the
same time, the tolerance of the remedy, as
a general rule, endures a shorter time with
the former than with the latter.  The ad-
ministration  of  antimonials to children
should be most carefully watched; as their
effects are sometimes  inordinately dispro-
portionate to the dose employed.  It is on
this account that antimonial wine should
not be used as  a domestic remedy; for
from being  given ignorantly, it has  not
unfrequently caused the death of children.
  We have  now finished the considera-
tion of the more important circumstances,
independently of dose, which modify  the
operation of the antimonial preparations.
Many of these circumstances increase the
 effect of the remedy; and it is impossible,
 under all the varying effects of these pre-
 parations  in different cases, to foresee the
 extent of their operation.  It therefore,
 sometimes happens, even to judicious prac-
 titioners, and not unfrequently to the bold
 and  empirical,  that antimony  produces
 such grave disorders of the digestive func-
 tions, as to call for the immediate discon-
 tinuance of the remedy, and the adoption
 of curative measures to relieve the arti-
 ficial  disease.  When the preparations, on
 their  first employment in proper  inflam-
 matory cases,  produce free vomiting and
 purging, these effects may be generally
 overlooked; as they are usually  of short
 duration, and disappear in the course of a
 day or two, by which time tolerance is es-
 tablished.   But  if they  should come on
 after the period  of tolerance, their occur-
 rence is then quite a serious matter. The
 measures  to be  adopted  under these cir-
 cumstances, besides the  immediate omis-
 sion  of the antimony, are the use of an
 amylaceous  diet, demulcent drinks,  and
 anodynes.   A convenient anodyne is fur-
 nished by the sulphate of morphia, which
 may be  given in half-grain doses by the
 mouth, or in double that quantity by injec-
 tion, every two hours, until the more ur-
 gent  artificial symptoms have subsided.
 As soon as this object has been attained,
 Trousseau recommends the  administra-
 tion of six-grain doses, three or four times
 a day, of  subnitrate of bismuth,  as well
 calculated to remove all remains of func-
 tional disorder of the alimentary canal.
   In  the  foregoing  remarks we  have
 presented  a number of considerations on
 the  diversified effects of the antimoni-
 als as a class, and on the different thera-
 peutic precepts  which are applicable to
 their  administration.  But every  antimo-
' nial is supposed to possess some peculiar
 properties  of its  own, which cannot be
 arranged under  the  generalities  belong-
 ing  to the whole class, and which conse-
 quently  require  to be  noticed under the
 head of each.   This is emphatically true
 with regard to tartar emetic, which pos-
 sesses, in some respects, peculiar proper-
 ties, and is susceptible of many applica-
 tions which belong to no other  antimonial.
 In noticing the antimonials as therapeutic
 agents, individually, we shall  begin with
 tartar emetic as the chief preparation, and
 treat  of the rest in the order in which
 they are noticed under the pharmaceutical
 head.
   Tartar Emetic.  Syn. Tartrate of an-
 timony and potassa;  Tartarized antimo-
 ny; Stibiated tartar;  Antimoniated tar- 
ANTIMONY.  (Therapeut.)                        53
tar.  The discovery of tartar emetic was
made about the year  1638,  and is attri-
buted to Adrian Mynsicht.  It was al-
ways considered the chief antimonial; and
the controversies which were so long kept
up respecting the antimonials, turned more
particularly on the merits or demerits of
this  salt.  At  first a large number of an-
timonial preparations were employed; but
in the  progress of time,  many  fell into
neglect so that  during the eighteenth
century, the prepared sulphuret, kermes
mineral, diaphoretic antimony, the glass,
antimonial powder, and tartar emetic were
almost  the  only ones  employed.   In pro-
portion to the progress of knowledge, the
number of preparations in use has gradu-
ally diminished; so that  at the present
day, the kermes,  antimonial powder, and
tartar  emetic  may be considered as the
chief  antimonial   remedies  prescribed.
Every day's experience, however, seems
to diminish the use of the two former, and
to increase that of the latter, showing that
the  evident tendency  of medical opinion
is to settle down upon tartar emetic as the
best preparation of the class. Indeed, many
distinguished  practitioners entertain the
opinion, that  there is no therapeutical ef-
fect that can be gained by other antimoni-
als, which cannot be equally well attained
by tartar emetic.  This assertion, without
limitation, may not be true; but still in
the great majority  of cases of disease,
where  an  antimonial would be proper,
every indication can  be fulfilled by the
use of this salt.  Besides, it has the ad-
vantage, when crystallized, of offering a
composition which  is always  identical;
except that it is subject to a trifling efflo-
rescence, which slightly increases its ac-
tivity under the same  weight.
   Like the antimonials generally, tartar
emetic is capable of producing, according
to the dose, and the state of the system,
an alterative, sedative,  diaphoretic, ca-
thartic, emetic, contro-stimulant, and cor-
rosive effect  It may be supposed also ca-
pable  of giving rise to  all these effects,
by whatever channel it may be introduced,
whether by the stomach, rectum, skin, or
veins.  It  is  indeed true, that particular
channels are  selected  when particular ef-
fects are sought for; as the skin, when its
corrosive  effects are desired; but even by
this channel,  the sedative or emetic effect
may be produced, by favouring the absorp-
tion of a diluted solution of the salt, in an
appropriate dose, by the denuded cutis.
   When  tartar emetic is given in  doses
of from the thirty-second, to the sixteenth
of a grain, largely diluted with water, re-
                  5*
peated every hour or two, so as to admin-
ister from a quarter to half a grain dady,
it may be continued for a long tune without
inconvenience to the patient, and acts as
an alterative. In a dose somewhat greater
(from the eighth to the sixth of a grain) it
is  capable of producing a general depres-
sion of the vital actions.  In a still higher
dose, varying from a grain to three or four
grains, it may be made to be actively ca-
thartic or emetic, or both.  Increasing the
dose still further, and managing the exhi-
bition, by the smallness of the vehicle, by
diet, &c,  so as to produce a support or
tolerance of the remedy, without vomiting
or purging,  or other  obvious  evacuation,
so strong an impression  is made upon the
vitality of the stomach, the centre of so
many irradiated actions,  as to produce a
general depression of the vital powers, on
the principle, as we believe, of revulsion,
but as Rasori would term it of contro-
stimulus.  Finally, when applied to a part
in the solid state, as for example the skin,
it acts as a corrosive. Thus it is perceived,
that according to the dose, state of dilu-
tion, condition of the system, and mode of
exhibition, tartar emetic becomes a totally
different, and sometimes  even a diametri-
cally opposite remedy.
   Considering  the diversified action of
tartar emetic, according to the dose, dilu-
tion, &c, no sweeping conclusion can be
drawn from its effects, when given in an
over-dose, to inferior animals, in determin-
ing its character as a therapeutic agent.
These effects are  violently irritant; but
this admission by  no means  proves that
tartar emetic is necessarily irritant.  Ex-
periments made on inferior animals, in in-
vestigating  the action of  medicines, are
certainly valuable; but there is reason to
believe, from the mode in which they are
conducted, that too hasty conclusions are
sometimes drawn;  and  that those effects
which  belong  to a substance under the
special circumstances of its employment
in an experiment,  have been  erroneously
attributed to it universally.  Accordingly
the exhibition of large or poisonous doses
of tartar emetic to animals, or the appli-
cation of such doses to wounds or mucous
surfaces, may enable  us  to decide on the
lesions which  such doses may produce,
but  throws  no light, or rather obscures
our reasoning, on the effects of minute  or
small doses of the  same remedy.  With
these limitations as  to the value of ex-
periments such as we have alluded to, we
shall proceed to notice the results of Ma-
gendie and others, obtained by that mode
of investigation. 
54                        ANTIMONY.  (Therapeut.)
   It results from the observations of Ma-
 oendie, 1. that tartar emetic, administered
 to middle-sized dogs, in doses of a drachm,
 rarely produces  bad effects; 2. that the
 younger the animals, the more susceptible
 are they of the action of this substance;
 3. that the duration of the vomitings and
 purgings  is proportional to the nervous
 susceptibility of the animal; 4. that the
 salt  is dangerous, only  when it is not re-
 jected ; so that  the more free the vomit-
 ing,  the less likely is it to produce dele-
 terious effects;  5.  that it is with tartar
 emetic as  with gunpowder, the more con-
 centrated, the more violent its action; 6.
 that  in consequence of  idiosyncrasy,  the
 same dose may cause one animal to perish,
 and fail to produce death in another of the
 same age, and apparently of the same vi-
 gour ; 7. that tartar emetic,  injected into
 the veins,  or brought in  contact with  ab-
 sorbing surfaces,  such as a loop of intes-
 tine, the cellular tissue, or the substance of
 the different organs, causes vomiting and
 purging, just as  it does when introduced
 directly into  the  alimentary  canal;  that
 death takes place after  a variable period,
 and  that the bodies always present the
 same alterations; 8. that these consist of
 an inflammation, more or less extensive,
 of the mucous membrane of the alimenta-
 ry canal, and blackish irregular spots in
 the lungs,  extending more or less deeply
 into the substance of these organs; 9. and,
 lastly, when tartar emetic causes death,
 the effect  is due rather  to the absorption
 of the salt than to any direct action which
 it exercises on the stomach.
   Rayer  repeated  the  experiments  of
 Maoendie, employing rabbits for the pur-
 pose  instead of dogs.  His results differ,
 in some respects, from those of Mage.ndie,
 and particularly in the absence of all le-
 sion  of the lungs, whether the animals
 were poisoned by half a drachm of the
 salt, introduced into the cellular tissue of
 the thighs,  or by  twenty-four grains, in-
 cluded by iigatures in a loop of intestine.
   Trousseau admits that  tartar emetic
 exercises on the tissues to which it is ap-
 plied  an energetic  irritant action;  but
 adds that its local effect is singularly mo-
 dified by  several  circumstances.  Thus,
 if a grain  of tartar emetic be placed on
the eye, it  produces a redness immediate-
ly, followed by violent inflammation.   In-
tense inflammation is also produced, when
the salt  is  brought  in contact with the
mucous membrane of the  genitals,  ear,
nose,  or mouth.   On the skin it produces
a pustular  eruption,  and  on the  mucous
membrane of the alimentary canal, under
 certain circumstances, powerftd irritation.
 Nevertheless this irritant action is not al-
 ways manifested; and Trousseau enters
 into an inquiry,  why the irritant effects
 of tartar emetic are sometimes produced,
 and sometimes absent.   In  pursuing this
 inquiry, he justly remarks that the eases
 are totally distinct, where tartar emetic is
 concentrated and cannot be thrown  off or
 displaced, as when applied to the skin .or
 any accessible mucous surface; and where
 it  is spread over a  large surface and  is
 constantly changing its position, as when
 passing through  the  alimentary canal.
 Thus he remarks, " where tartar emetic
 is  swallowed,  it  produces less local ef-
 fects ;  because, in the first place, it is in
 great part expelled  by vomiting; in  the
 second place, it passes rapidly through the
 track of the intestine, and  consequently
 but small quantities are in contact with the
 same part; in the third place, the stools car-
 ry off  the greater portion of that which
 is left; and, besides, the assimilating pow-
 er of the digestive organs has a tendency
 to neutralize the irritant  action of a cer-
 tain quantity of the  salt.  Moreover, this
 digestive power may,  under certain cir-
 cumstances, be so strong, that enormous
 doses of tartar emetic, half an  ounce  for
 example, may be given many days in suc-
 cession, without being followed by any ap-
 preciable  disorder of the mucous mem-
 brane of the alimentary canal."
   In support of the views here taken by
 Trousseau, of the influence of modifying
 circumstances  on  the ordinary irritant  ac-
 tion of tartar emetic in  large  doses,  we
 may cite  the  post-mortem examinations
 of Rayer, in the  few fatal cases of pneu-
 monia which occurred under his care,  af-
 ter being treated by the Rasorian method.
 He did  not find the stomach and intestines
 notably inflamed,  except in one case, in
 which the mucous membrane of the sto-
 mach presented a rosy tint.  In another
 case, in which but seven or eight grains
 of tartar emetic were used,  the veins of
 this viscus were prominent, and distended
 with blood, which  could be made to circu-
 late by  pressing them with the  finger; a
 condition of the vessels which appeared to
 be owing to the difficulty of the circula-
 tion just before death; for the  liver and
 spleen were gorged with blood.  In all the
 cases, the  mucous membrane had its na-
 tural consistence and thickness, and peeled
off by means of the  nail, in large layers,
as it does in its healthy state.  Rayer then
adds, that  all the patients who died, en-
tered the hospital  in the  second or third
stage of the  disease, and, therefore, at a 
ANTIMONY.  (Therapeut.)                        55
period too  late to allow  of much tartar
emetic to be taken. Strambio relates that
upon examining the bodies of many indi-
viduals who died of pneumonia after hav-
ing been treated by Rasori, and who had
taken from twelve grains to the enormous
dose of half an ounce of tartar emetic,
the stomach in some was interiorly cover-
ed with a  red liquid resembling a syrup
highly charged with kermes, and its mu-
cous  membrane presented a red appear-
ance ; while in others, no lesion either of
the stomach or lungs could be  detected,
sufficient to explain the fatal termination.
In these latter cases,  Strambio  supposes,
that death took place in consequence  of
the exhaustion of the vital forces, deter-
mined by the enormous doses of the anti-
monial ; and this explanation must be ad-
mitted as correct provided death occurred
soon after their administration.
  We shall now return from this digres-
sion as to the effects of large doses of tar-
tar emetic  on the system, and the lesions
which they are capable of producing, to
the examination, under separate heads, of
the distinct therapeutic  effects of tartar
emetic, which constitute  it, in each  of
those effects, virtually a distinct remedy.
  a.  Tartar emetic as an alterative. Em-
ployed in this manner by the use of very
minute doses, it has  been recommended
by  Lanthois of Montpellier, in incipient
phthisis.   His mode  of exhibition was to
dissolve a grain of tartar  emetic in eight
table spoonfuls of distilled water, and to
add this solution to six or eight pints of
water.  This very dilute solution was used
by  the patient as his common  drink, at
meals, or at any other time, without limita-
tion, its use being attended with  no incon-
venience.  The way in which it acts is by
lessening the  force and frequency of the
pidse, independently of any  nauseating
effect, and, perhaps,  by  removing struc-
tural disease, as a consequence of increas-
ing- the activity of the absorbents.   Dr.
Eberle has used tartar emetic in the man-
ner recommended by Lanthois, in several
cases of phthisis, and with better effect than
that derived from any other remedy which
he had used in that disease. On the recom-
mendation  of a friend, we gave the same
remedy in half-grain, and afterwards grain
doses in the twenty-four hours, dissolved in
a pint of water, in a case of disease threat-
ening consumption, and attended with fre-
quent  pulse,  and occasional spitting  of
blood.  The remedy produced occasionally
a little nausea,  and  was attended with a
marked reduction of the pulse, and  a
general melioration of the symptoms.  Tar-
tar emetic may be given  in the quantity
of half a grain in the twenty-four hours,
dissolved  in a  pint of water,  for a  long
time, without any inconvenience  to the
patient, not even a reduction of appetite;
and yet with the result of producing bene-
ficial changes in various chronic diseases.
Dr. Balfour speaks in high terms of its
use in  small doses, not only in acute affec-
tions, but also in chronic disorders; its effi-
cacy  not  being confined  to  nauseating
doses.  Tartar emetic is also useful in mi-
nute doses, long continued, in chronic cu-
taneous diseases. When employed for this
purpose, it may be sometimes  advantage-
ously used in  conjunction with guaiac,
extract of hemlock, or infusions of sarsa-
parilla or dulcamara.
  b.  Tartar emetic as a sedative and dia-
phoretic.   This remedy  may  be useful,
by reason principally of its sedative and
diaphoretic powers, in 'doses of from  an
eighth to  a  sixth of a  grain,  repeated
every two  or three hours, in most febrile
diseases, in the different phlegmasia?, ex-
cept gastritis and enteritis, and in the ac-
tive hemorrhages.  Its mode of action has
been sufficiently  dwelt upon  in the re-
marks  already made under the  head of the
general effects of antimonials as antife-
brile and antiphlogistic remedies. In gain-
ing these effects, it is frequently useful to
combine it with some neutral salt such as
nitre or sulphate of magnesia, neither of
which  have the power to decompose  it.
Sulphate  of  magnesia is  a particularly
useful  addition, when a slight action  on
the bowels is desired. Again, many cases
exist in which the addition of calomel, or ■
of calomel and nitre to this  antimonial
proves useful, where it is desirable, in ad-
dition  to an antiphlogistic effect, to pro-
duce  an action on  the  hepatic system.
The latter combination, under the name
of nitrous powders,  is  frequently  pre-
scribed in the United States in febrile dis-
eases, prepared according to the following
formula: R Pot Nitrat 3i, Ant et  Pot.
Tart. gr. i, Hyd. Chlor. Mit gr. vi.   Ft.
pulvis, in  chart sex vel octo dividendus.
S. One to be taken every two hours. Dr.
Eberle, on the authority of Pfaff, a  Ger-
man writer on the Materia Medica, re-
commends the union of  Peruvian  bark
with tartar emetic, in some cases of inter-
mittent fever, in which, from  an inflam-
matory condition of the system, bark alone
would do harm.  From the use of bark in
this way, the antimonial is disarmed, to a
certain extent, of its emetic power, and
may  be given to the extent of one or two
grains  every three or four hours, without 
56                        ANTIMONY.

producing vomiting, but with a  manifest
antiphlogistic  effect.  In judging  of the
propriety of this practice1 it is freely con-
ceded that bark decomposes tartar emetic,
and lessens its activity;  but how far it is
possible by such a combination, to gain at
the same time the antiphlogistic influence
of the antimony, and the febrifuge impres-
sion of the bark, is a point which may
well be  left to future  decision.  If the
practice should be found on experience to
be valuable, a question will arise whether
the increased doses of tartar emetic which
may be given, are necessary only to make
up for the loss of activity in the antimonial,
or are really useful by being, to a greater
extent, absorbed in the  changed and less
irritant  state to which the antimonial is
brought by the bark
  Tartar  emetic in  sedative doses ope-
rates usefully as  an adjuvant to  bloodlet-
ting, and the other antiphlogistic measures
usually employed in active hemorrhages,
and may be  supposed to operate on the
principle of reducing the  action  of the
heart and arteries.
  The power  of tartar emetic as an ex-
pectorant  has  not been made a distinct
head in our account of its diversified the-
rapeutic  action.  This  power,  however,
has been  fully proved by ample experi-
ence; and  as  it is  intimately connected
with its diaphoretic  effect we shall men-
tion it here.  It is well known that tartar
emetic in doses  of from  a twelfth to a
tenth of a grain, causes the pulmonary ex-
halants to yield a thinner and more abun-
dant secretion, and thus proves useful  in
some forms and stages of thoracic disease,
in which the sputa is viscid, and  deficient
in quantity. In such cases, its expectorant
power may be increased by associating it
with ammoniac or squill.
  c.   Tartar  emetic as a  cathartic and
emetic.  Tartar emetic given in half-grain
doses, will generally produce purging fol-
lowed by diaphoresis.  As an emetic, it is
usually administered in the dose of two or
three grains, or of a grain dissolved in a ta-
ble spoonful of water, every ten or fifteen
minutes until it vomits.   It is often con-
joined with ipecacuanha, in the propor-
tion of one or two grains to twenty of the
vegetable emetic.  The method of giving
it in divided doses, however, is to be pre-
ferred ; for, in consequence of idiosyncra-
sy, the full emetic dose sometimes pro-
duces dangerous effects, such as excessive
vomiting and  purging, attended  with co-
licky  pains,  a  small and  concentrated
pulse, and a cold and clammy skin. After
nausea is  fully produced, or vomiting has
 (Therapeut.)

commenced, the  operation  is to be pro-
moted by warm water, or warm chamo-
mde tea.  The warm diluents render the
vomiting  easier and  more  copious, and
prevent that excessive prostration which
sometimes occurs, when,  from the small
bulk of the vehicle, even dangerous quan-
tities of the antimonial are taken with-
out the occurrence of emesis. Full vomit-
ing  being produced,  it seldom fails to
cause purging; so that as a general rule,
whenever it acts as an emetic, it operates
also as a cathartic.   This double effect,
however, is most usually gained by a com-
pound solution of tartar  emetic, either
with sulphate of soda, forming the famous
emetico-cathartic of the French School,
or, what is better, with sulphate of mag-
nesia.
  In giving  this antimonial as an emetic,
it is sometimes added to lemonade, to the
infusion of tamarinds,  or even to a strong
decoction of Peruvian bark.  All  these
vehicles  alter its chemical qualities; the
two former,  from  the acids they contain,
increasing, the latter, diminishing its ac-
tivity.  Antimoniated  lemonade, the li-
monade emetisee  of the French, is gene-
rally made in the proportion of two grains
of the emetic salt to the pint Full vomit-
ing may be induced by the addition of tar-
tar  emetic to the decoction of cinchona;
for  though it  is in part converted into a
tannate of antimony, yet sufficient activity
remains for  that purpose.  The  repeated
vomitings sometimes produced by the bolus
ad quartanam, administered at the hospi-
tal La Charite, in Paris, and which  con-
sists of sixteen grains of tartar emetic,
associated with one or two drachms of
bark, sufficiently attest the  power of the
antimonial, even after the decomposition
which it undergoes from this vegetable.
  The emetic effect  of this antimonial
may sometimes be gained, in cases where
it cannot be taken by the mouth, by giving
it in the form of enema, in doses of twenty
grains or more, dissolved in a pint of wa-
ter ; but when thus administered, it gene-
rally acts  exclusively as a cathartic, and
as such forms a most valuable resource in
the treatment of obstinate obstructions of
the bowels.
  Tartar emetic, as a vomit, is character-
ized, in its operation, by certainty, strength,
and  permanency  of  effect  It remains
longer in the  stomach than ipecacuanha,
produces more frequent and longer  con-
tinued efforts to vomit and exerts a more
powerful impression on the system gene-
rally.  As an  emetic,  its use is indicated
where the object is not merely to evacuate 
ANTIMONY.  (Therapeut.)                        57
the stomach, but to agitate and compress
the liver and other abdominal viscera. By
the extension of its action to the duode-
num, it causes copious discharges of bfle,
and hence forms an appropriate remedy in
those diseases in which there  is an accu-
mulation of that secretion.  It is employed
as an emetic in the commencement of fe-
vers, especially those of an  intermittent
or bilious character, in jaundice, whooping-
cough,  croup, chorea, idiopathic  tetanus,
and a long catalogue of other diseases. It
is contra-indicated in diseases of debility,
in the advanced stages of febrile affections,
and in fevers attended with extreme irri-
tability of stomach.
   Laennec treated with success  three
cases of chorea and two of idiopathic te-
tanus,  by large doses of tartar emetic. Its
mode of operation is not distinctly stated;
but it  may be presumed that  it acted by
vomiting and purging, and  by that ex-
treme  relaxation of the muscular system,
which is found  to be connected with eme-
tic doses of this antimonial.
   Advantage has been taken of the ex-
treme  muscular  relaxation produced by
this substance  to facilitate the reduction
of dislocated limbs. This practice appears
to have originated with Mr. Wilmer, and
since the publication of his paper, its value
has been repeatedly verified in  surgical
practice.  Bloodletting to fainting answers
the same  purpose; but the  objection to
this expedient is  that large quantities of
blood must often  be drawn, and that the
patient is  left  proportionally  weak after
the reduction of the limb. Taking advan-
tage of the same power of producing mus-
cular relaxation, Dr. Chapman has used
tartar emetic by way of enema, with en-
couraging success, in a case of idiopathic
locked-jaw.
   d. Tartar emetic as a contro-stimulant.
Rasori, professor of clinical medicine at
Milan, published in 1800 his views on the
therapeutic action of tartar emetic in large
doses,   in  controlling  inflammatory ex-
citement in certain phlegmasial diseases,
particularly peripneumony.   He  denoted
the condition of high  excitement charac-
terizing these diseases, as the diathesis of
stimulus; and hence he called tartar eme-
tic in large doses, as administered by him,
a contro-stimulant. Peschier of Geneva,
Laennec,  and many  other practitioners
confirmed the general accuracy of his re-
sults ; and  no one at present calls in doubt
the curative power of tartar emetic, in
large doses, in the treatment of peripneu-
mony.   It has also been recommended, in
the same doses, in several other diseases;
such  as  hemoptysis,  pleurisy,  articular
rheumatism, apoplexy, traumatic tetanus,
encephalitis, phlebitis, puerperal peritoni-
tis, &c.  Numerous observations have in-
contestably  proved,  that tartar  emetic,
given by the method of Rasori, will con-
trol most acute inflammations; but it is
doubted by many physicians, whether the
practice  is safe, and whether it does not
infinitely more harm  to the digestive or-
gans, than good in  subduing local inflam-
mation  in other parts.  The  particular
mode in which it acts, according to the
views of Rasori, wdl be detailed in an-
other article: (see Contro-stimulant.) Some
have  supposed its mode  of action,  when
given by the method of Rasori,  to be
sedative; but  its mere power to diminish
inflammatory  excitement by  no  means
proves it to be  so.  We  believe,  with
Broussais, that it acts as  a powerful re-
vulsive on the stomach;  but without en-
tering, in detail, upon the theory  of its
operation, we  shall use the term contro-
stimulant, to express the mode of action,
whatever it  may be, of tartar emetic,
when given in the manner recommended
by Rasori.
  According to this last writer, tartar eme-
tic, in large doses, so as to produce its con-
tro-stimulant operation, is borne only in the
sthenic  or inflammatory  condition of the
organism, or,  as he expresses  it during
the existence of the diathesis of stimulus.
This explanation of the  tolerance of the
remedy,  in doses which  under other cir-
cumstances would prove poisonous, is con-
sonant with  pathological principles; but
while Trousseau admits that the remedy
is never better supported than when the
inflammatory symptoms are most intense,
he nevertheless asserts that he has seen
tolerance to be perfectly established in pa-
tients excessively weak.   He, therefore,
denies that the inflammatory condition is
essential to  the tolerance of antimonials,
and  explains  the fact that they are not
well borne in health, by the circumstance,
that a rigorous diet an essential condition
of tolerance, is not adopted. The different
view of Trousseau on this subject may
be explained by the fact that he prefers
the use  of  the oxides, in obtaining the
contro-stimulant effect of antimony, pre-
parations which produce incomparably less
irritation and disturbance of the system
than tartar emetic.
  The chief disease in which Rasori has
given tartar emetic as a contro-stimulant
is peripneumony.  His principles of treat-
ment may be summed  up under the follow-
ing heads: 1. To treat the disease through- 
58                        ANTIMONY.

out by  tartar emetic; 2. To  adopt this
medicine as the principal, and sometimes
the only remedy in the disease; 3. To di-
minish by its use the number of bleedings,
or to do away the necessity of this evacua-
tion altogether;  4. To give the remedy in
doses which  formerly the boldest practi-
tioners  never  thought  of  employing;
amounting to one or more drachms in the
twenty-four hours, and to several ounces
in the course of the disease, without pro-
ducing either vomiting or purging.
  Rasori, and the  Italian physicians, in
treating peripneumony, generally give at
first from ten grains to a scruple of tartar
emetic, and increase the dose gradually to
one or several drachms in the twenty-four
hours, in proportion as the tolerance of the
remedy is gradually established.  Laen-
nec, who with M. Kapeler, were among
the first to call attention to the method of
Rasori in France,  adopted it with slight
modifications.   When a  patient with pe-
ripneumony would bear a bleeding, Laen-
nec began the treatment by drawing from
eight to sixteen ounces of blood; and rarely
repeated the  venesection,  unless in indi-
viduals attacked with diseases of the heart
or threatened with apoplexy or some other
sanguineous congestion.  He states, how-
ever,  that he has frequently and  rapidly
cured intense peripneumonies without re-
course to bleeding, though generally he
resorted  to  it   Immediately after the
bleeding, he gave a  grain of tartar emetic
in two nuidounces and a half of sweetened
aromatic water, and  repeated the dose
every two hours, until six had been taken;
after  which  the patient  was allowed to
rest for seven or eight hours, if the symp-
toms were not urgent, and a disposition to
sleep  was manifested.   But if the disease
was already advanced, the oppression great
the head seized,  and both lungs affected,
or if one of them was invaded throughout,
he was in the habit  of continuing the tar-
tar emetic without interruption, until the
symptoms were mitigated, and the stetho-
scope indicated an improvement.   When,
however, the aggravating circumstances,
above mentioned, were all united in the
same  case, his practice was to increase
the dose of the antimonial to a grain and
a half, two grains, or even two grains and
a half,  but  given  always in the  same
amount of vehicle.
  Laennec remarks, that some pneumonic
patients support tartar emetic, adminis-
tered  in this manner, without vomiting or
purging.  A  majority,  however,  vomit
several times, and have five  or six stools
the first day; but afterwards they  experi-
 (Therapeut.)

ence but moderate evacuations, and often
none at all.  After the tolerance  of the
medicine has been established, it is  assert-
ed by Laennec, that the patients often be-
come constipated, so as to require the use
of purgative enemata.
  In describing  his mode  of practice,
Laennec proceeds to remark, that when
evacuations continue to the second day,
or when there is reason to believe that the
tartar emetic will be supported with diffi-
culty, he adds to the six doses to be taken
in twenty-four hours, one or two  ounces
of the  syrup of diacodion (syrup  of pop-
pies), an addition which he admits  is con-
trary to the theoretic  views of Rasori,
but which his own experience has  proved
to be useful.  He declares further that in
general, the effect of the tartar emetic is
never more rapid than when it causes no
evacuation whatever; though  sometimes
its good effects are accompanied by a gene-
ral sweat  Though he considers frequent
vomiting and abundant purging to be fear-
ed, on account of the  weakness, and the
irritation of the alimentary canal  which
they produce, yet he avers that he  has ef-
fected  remarkable cures, where the eva-
cuations were very abundant   " I  have,"
says he, " very rarely met with pneumonic
patients who could not support tartar eme-
tic, and such cases occurred in my first
trials;  so that this inconvenience is attri-
butable, perhaps, to the  inexperience and
want of confidence of the physician, rather
than to the method itself.  Ln many cases,
where  a patient would support, only tole-
rably, six grains of tartar emetic with sy-
rup of diacodion, one day, I have given
him the next day nine grains with  perfect
tolerance.  At the end  of twenty-four or
forty-eight hours at most and often at the
end  of two or three hours, a marked me-
lioration of all  the symptoms is obtained.
Sometimes, even, a patient who appears
to be doomed to certain death, is,  at the
end  of a few hours, out of danger, with-
out having experienced any crisis  or eva-
cuation, or any other notable change than
a progressive  and rapid improvement in
all the symptoms; and the exploration of
the chest explains the reason of the sud-
den  change, by detecting all the signs of
resolution."
  Laennec states  that  effects  equally
striking may be  obtained at all stages of
the disease, even when a great part of the
lung is infiltrated with pus!
  From the  moment   an  improvement
takes place, Laennec conceives that the
medicine may be continued with the cer-
tain result of completing the resolution, 
ANTIMONY.  (Therapeut.)
59
without inducing fresh commotions; a cir-
cumstance in which mainly consists the
great practical advantage of tartar emetic
over bloodletting as a remedy.  By bleed-
ing, he admits that we almost always ob-
tain a diminution of fever, of oppression,
and of bloody expectoration; but at the
end of some hours, these symptoms again
increase; and this often hafppens five  or
six times, after the employment  of  as
many bleedings.  Now Laennec affirms
that he had  never seen similar  relapses
under the use of tartar emetic;  and that
when this antimonial was employed, the
weakness during convalescence was never
so  protracted, or excessive, as when the
patient was  treated  by repeated bleed-
ings.
   We by no  means subscribe to the accu-
racy of all the above views of Laennec,
in relation to the tartar emetic treatment
in  peripneumony; but though his  asser-
tions may have been too general  on some
points, and his plan of practice too  little
regulated by the state of the alimentary
canal, still the opinions of so distinguished
an  authority must always be viewed  as
important and entitled to great respect.
  M. Peschier  of Geneva, advocates the
contro-stimulant  use  of tartar emetic  in
peripneumony, and in fluxions of the chest
generally; but his mode  of using  it ap-
pears by no means precise, and not  at  all
regulated  by the state  of  the  system.
When a  determination to the skin was
manifested, he added nitric, muriatic, or
acetic ether to the antimonial; and when
there existed dysuria, and dry heat of the
skin, he  conjoined nitre.   He generally
began the treatment with six grains in the
twenty-four hours, and increased the quan-
tity three grains daily,  until the dose
reached twelve  or fifteen grains, a quan-
tity which he did not exceed, as this was
found sufficient   In cases in which, from
the great weakness of the patient, he was
induced to direct so small a  dose as a
grain, or  a grain  and a half, it produced
fatiguing  effects, without any curative re-
sult  In none of the cases which he treat-
ed, was bloodletting, either general or  lo-
cal, employed, but blisters were occasion-
ally resorted  to.
  Without implicitly relying on the re-
sults  obtained by  Rasori,  Laennec, and
M.  Peschier, from the use of tartar eme-
tic  as a  contro-stimulant,  their  general
tenour is sufficiently coincident to satisfy
the reader of the  remarkable controlling
power of this remedy, when thus  employ-
ed,  over acute pneumonic mflammation.
Still the question arises how far the prac-
tice  is a safe one, and how far it may be
used  to  replace  the  ordinary curative
means, of general and local bloodletting,
blistering,  antiphlogistic medicines, de-
mulcents, and anodynes.  In determining
this question, the  more recent results de-
duced by M. Rayer from careful observa-
tions made on a number of pneumonic pa-
tients at the hospital La Charite, will have
an important  bearing, from the impartial
manner in which they appear to have been
conducted.   M. Rayer  arranges his ob-
servations under the three heads, of effects
on the digestive organs, on  the  organs of
respiration, and on  the circulation and
blood.
  Effects on the digestive organs of pneu-
monic patients.—1.  Tartar emetic, dis-
solved in a small  quantity of sweetened
vehicle, produces vomiting less easily than
when it is dissolved in pure water, and
assisted by the administration of warm
and nauseating drinks.
  2. The tolerance of the remedy was ob-
tained in a few patients from the first day,
without any apparent reason for its want
of action on the stomach or bowels.  Now
this tolerance is affirmed to take place in
a great  number  of  patients  by Rasori,
and in many  by Laennec
  3. The majority of the patients vomit on
the first day, after having  taken the firi-t
doses. They  experience at  first a general
uneasiness with disposition to  vomit af-
terwards paleness, and  contraction of the
volume of" the body.   After vomiting, re-
action and heat return in  the  course of
half an hour  or an hour.  During the in-
terval, the patient is pale, with  a  small
concentrated  pulse,  and yet he declares
himself to be better.
  4.  Some patients, from  irritability of
the digestive organs, support the contro-
stimulant method with difficulty, being af-
fected with violent vomitings,  colics, and
twistings of  the bowels.
  5. Tolerance is established more freely
and permanently in relation  to the stomach
than  to the bowels;  many  patients expe-
riencing purging without vomiting*after
the first days.
  6. In patients with  healthy  stomachs,
the vomitings and purgings were not pre-
ceded or followed by pains in the  abdo-
men, and were not  accompanied by any
pain except that attendant  on the act of
vomiting. The next  day the stomach and
bowels were rarely affected with pain.
  7. The alimentary canal soon loses its
power of tolerance;  for  if the treatment
be discontinued for a day or two, the same
doses, which  had ceased to produce vomit- 
60                        ANTIMONY.

ing and purging, and  even smaller doses,
will reproduce them.
  8. Tartar  emetic  may  be  given  for
many days together in very large doses to
some  pneumonic  patients,  without pro-
ducing  any evident inflammation  of  the
alimentary canal;  but this is not always
the case.
  9. If on the one hand,  the generality
of physicians have exaggerated the irri-
tant properties of tartar emetic; on  the
other,   the  contro-stimulists  have been
guilty of an opposite exaggeration, far
more dangerous.
  10. When it is wished to establish a
tolerance of the remedy,  it is better to
augment the dose gradually, or even to di-
minish  it rather than to  employ opiates,
which give rise to a  factitious tolerance,
masking the effects of the antimonial on
the digestive organs.
  11. Tartar emetic, administered in large
doses, produces sometimes inflammation
of the stomach and bowels;  but these ar-
tificial inflammations are, in general, less
serious  and obstinate than those generated
without appreciable  causes;  and  when
they  are not kept up  by the  too long-
continued action of the remedy, nor ag-
gravated  by a previous affection of the
stomach, they yield, with sufficient readi-
ness, on the  suspension of the remedy, or
to the use of a few local bleedings.
   12. During the  convalescence of pneu-
monic patients, in  whom resolution  is pro-
gressing, tartar emetic, in the dose of five
or six grains, appears  to excite the feeling
of hunger.   After tolerance has been es-
tablished, digestion does not appear to be
deranged by the remedy,  when adminis-
tered three hours  before or after a meal.
It may  be proper to remark, that many of
M. Rayer's  patients were on half-diet.
   13. In this  paragraph,  M. Rayer re-
ports the post-mortem appearances observ-
ed in the few pneumonic  cases which he
lost  These have been detailed in  a  pre-
ceding  part of this article. (See p. 54.)
  Effects on the organs of respiration.—
1. Hie effects of tartar emetic, in large
doses, upon the organs of respiration, vary
according to the intensity of the peripneu-
mony, and to the disturbance, more or less
serious, which  it impresses on the diges-
tive organs.  M.  Rayer  has  seen peri-
pneumonies disappear in forty-eight hours
after repeated vomitings and purgings by
tartar emetic.   He  has  observed  other
cases in which the disease progressed, al-
though there was a marked tendency to
tolerance.   In  a considerable number of
cases, the cough and bloody expectoration
(Therapeut.)

diminished in an evident manner, and in
the following days the stethoscope detect-
ed the progressive march of resolution.
  2. By means of this treatment, and by
the use solely of tartar emetic, many peri-
pneumonies, both simple and double, were
completely cured, and  in as  short a time
as when treated by bloodletting.
  3. The good effects of tartar emetic are
never more  evident,  according to the
opinion of M. Rayer, and in opposition to
that of Rasori, than  when  it produces
abundant evacuations.   Indeed,  the ab-
sence of tolerance, signalized by Laennec
as one of the contra-indications of tartar
emetic, is, according to M. Rayer, on the
contrary, oftener one of  the conditions
most favourable to its employment pro-
vided the stomach be not inflamed.
   4.  The first  days of the use of tartar
emetic in recent peripneumonies are dis-
tinguished by a decided melioration of the
disease;  but this  improvement  becomes
afterwards less and less evident,  from the
tolerance of the remedy, and from the fact
that  those  diseased conditions disappear
first which are the least fixed.
   5.  The property attributed  to  tartar
emetic of augmenting the energy of in-
terstitial absorption, so as to resolve pul-
monary hepatizations after bleedings have
lost their influence, has appeared to M.
Rayer to be a very questionable one in
the majority of cases.
   6.  The quantity of tartar emetic neces-
sary  to effect  the cure  of peripneumony
varies  from several drachms to one or
more  ounces, according  to the extent of
the pulmonary inflammation, and the dura-
tion of the disease before the  treatment is
commenced.
   Effects on the circulation  and blood.—
When tolerance is established, the  action
of tartar  emetic  on  the circulation is
scarcely  appreciable;  on  the contrary,
when vomiting is about to take place, and
during the existence of colicky pains, the
pulse becomes concentrated.  With regard
to  the  buffy appearance so uniformly ex-
hibited by  the blood  in pneumonia,  M.
Rayer ascertained that this appearance
was  not  modified by the tartar emetic
treatment.
   M. Rayer sums up his results  by de-
claring that, in his opinion, the treatment
of peripneumony by tartar emetic,  as an
exclusive method, is inferior, in a majority
of cases, to the treatment by bloodletting.
   Before resorting to the method of Ra-
sori, Rayer further remarks,  it is neces-
sary to be satisfied as to the  condition of
the digestive organs.  It must not be for- 
ANTIMONY.  (Therapeut.)                       61
gotten that many individuals have latent
affections of  the stomach, and that cer-
tain results  of  chronic  gastritis in  old
persons, such as thinning and softening of
the stomach,  are  always aggravated by
tartar emetic.  Moreover, this method is
hurtful, when the pneumonia is compli-
cated with gastritis.   But when the in-
tegrity of the digestive organs is well as-
certained, it will be proper, according to
M. Rayer, to employ tartar  emetic and
bleeding concurrently in the treatment of
peripneumony. This combined method he
conceives to be preferable to all others at
the commencement of pulmonary inflam-
mations ; but instead of aiming to produce
tolerance, it  is  preferable,  according to
him, to obtain abundant evacuations. Six,
eight, ten, or fifteen grains of the antimo-
nial are considered sufficient by him to
produce this  result;  it being unnecessary
to  increase  the quantity daily until the
dose reaches  a drachm.   He, accordingly,
characterizes  it as a blameable temerity
to  imitate Rasori, who has often  given
the almost incredible quantity of an  ounce
in the course of a day. Finally, M. Rayer
recommends,  that in proportion as resolu-
tion progresses, the  dose of the  tartar
emetic should be diminished, having care
always to continue it for some time after the
disappearance of the crepitant rhonchus.
   We have  presented thus fully the re-
sults of M. Rayer, on account of their in-
trinsic value, and  of the precision with
which they are reported.  But we cannot
admit all his therapeutic views, and par-
ticularly that one which asserts that the
contro-stimulant action of tartar emetic is
never more marked than when it produces
copious evacuations, and that the establish-
ment of tolerance is rather detrimental than
useful to that action.  The great authority
of  Laennec  is opposed to it, and the ob-
servations of Rasori, M. Peschier, M.
Trousseau, and of many other practition-
ers, establish a diametrically opposite con-
clusion.  We admit the concurrent benefit
of  bloodletting, and cannot  conceive how
it could interfere with the curative  opera-
tion of the tartar emetic.   Dance agrees,
on this  point, with  M. Rayer; but M.
Trousseau states emphatically, as the re-
sult of his  experience,  that bloodletting
in  peripneumony, so far from  assisting,
impedes the  operation of antimony.  He
asserts that  resolution  is not completed
for a long time, when bleeding is employ-
ed  ; while it is never more rapid than un-
der the  sole  influence of antimony.  In
short, he declares it as the chief merit of
the cure  of  peripneumony  by antimony,
   VOL. II.          6
that there is no convalescence.  Patients,
according to him, are sometimes brought,
in the course of a few days, from the brink
of the grave to a state of apparent health
so satisfactory, that, without the indica-
tions of the stethoscope, it would be im-
possible to believe that  there had existed
a dangerous peripneumony. Of fifty-eight
pneumonic patients treated by M. Trous-
seau, none of whom were bled in the hos-
pital, and five only before  admission, but
two died.  The  cases most rapidly cured
by the antimony were precisely those  in
which  the disease  was  most recent, the
fever most vehement, the pulse most full
and vibrating, the skin hottest, the oppres-
sion greatest,  the  local  pain most acute,
and the expectoration most bloody.
  Tartar emetic as a contro-stimulant has
been given in haemoptysis and pleurisy,
but with doubtful  advantage.   Laennec
contended that it had the  power of con-
trolling  the inflammatory action  in the
latter disease; but M. Trousseau  reports
that, in ten cases  in which he tried anti-
mony in acute pleurisy, no reduction  of
the diseased excitement was obtained.
   According to Laennec, acute  articular
rheumatism, is,  after peripneumony, the
inflammatory disease in which tartar eme-
tic in  large doses appeared to him to be
the most efficacious.  The mean duration
of  rheumatism,  treated by this curative
plan, was seven or eight days; while, by
the ordinary method of treatment by bleed-
ing, &c, it is known to last from one to
two months.  The medicine, however, is
less efficacious,  where muscular and arti-
cular rheumatism are combined.  Laen-
nec sometimes though rarely observed  re-
lapses after articular rheumatism, when
the medicine  had not been discontinued;
and he was obliged, in two cases only, to
interrupt its use, because tolerance could
not be established.  Of thirteen rheumatic
cases treated  by Laennec, tartar emetic
proved highly useful in eight, without  ef-
fect in two, hurtful in one, and of doubtful
utility in two.
   M. Rayer dissents from Laennec as to
the value of the contro-stimulant practice
by tartar emetic in rheumatism; and rests
his dissent on the variable character and
duration of this disease, which forbids the
adoption of any opinion as rigorously ex-
act, in favour of any particular plan  of
treatment  Upon the whole, he comes to
the conclusion,  in opposition to Laennec,
that the plan by bloodletting, and by  re-
vulsives applied to the skin,  is preferable
to  that by tartar  emetic  in large doses.
Besides, tartar emetic is strongly contra- 
62
ANTIMONY.  (Therapeut.)
indicated in cases in which the rheumatic
disease is partly seated in the digestive
organs, or likely to be translated to them.
Rayer concludes by remarking " that the
employment  of tartar  emetic  in large
doses in rheumatism is more rarely indi-
cated than in pneumonia;  for the danger
to life, in the latter disease, is  such as to
make it admissible to produce a momenta-
ry or sustained revulsion on the stomach
and  intestines; whUe it is by no  means
demonstrated that this is equally true with
regard to rheumatism."
   M. Trousseau reports  his  experience
with the use of large doses of tartar eme-
tic in acute articular rheumatism, and is
of opinion that, when of service, it does
good  by operating as  an emetic and  ca-
thartic, rather than as a contro-stimulant.
Its good effects, however, are by no means
so constant as  in pneumonia; and so far
from acting on the principle of tolerance,
it is never so useful, according to him, in
acute  rheumatism, as when  it produces
vomiting and hypercatharsis. It is on this
account that M. Trousseau denies to the
antimonials the possession of any special
curative power in  this disease, and attri-
butes their efficacy exclusively to their
action as evacuants.
  Laennec and other practitioners have
employed contro-stimulant doses of tartar
emetic in apoplexy. Of eleven cases treat-
ed on this plan, six were cured;  but as
bloodletting was used at the same time, it
is impossible to determine the precise  cu-
rative value of the tartar emetic. In some
cases of apoplexy, Laennec has gradually
carried the dose  to a drachm and a half;
but it should be recollected that m conse-
quence of the lesion of the nervous system
which exists, the tolerance of the antimo-
nial in this disease is often apparent,  not
real, and, therefore, cannot be held as proof
of the safety of the stomach.
  MM. Delpech and  Lallemand have
recently extended the contro-stimulant use
of tartar emetic to the  prevention  and
cure  of tetanus from traumatic lesioiis.
Their results were made known by M. J.
Franc, one of their pupils, in a Memoir
published in 1834, from which it appears
that  the exhibition of  tartar emetic  in
large doses prevents the accidents which
follow those lesions; and, when these  ac-
cidents have  already  taken place, forms
the  most  efficacious  means  of treating
them.  By this treatment,  M. Lallemand
has cured, in many cases, a  slight and
commencing encephalitis, the consequence
of traumatic lesions.  The dose of the an-
timonial which he employs in the twenty-
four hours, is generally eight grains, asso-
ciated with the syrup of poppies.   Del-
pech, however, gives the remedy in sim-
ple aqueous solution without any addition.
  M. Trousseau reports several cases of
phlebitis and  puerperal peritonitis, suc-
cessfully treated by tartar  emetic and
other antimonials, used  as  contro-stimu-
lants.
  In concluding our remarks  on the con-
tro-stimulant use of tartar  emetic,  it is
hardly necessary to  add  that  its employ-
ment in this way is strongly  contra-indi-
cated in inflammation of the stomach and
bowels. M. Fabre has reported a case of
combined bronchitis and gastritis, in which
the administration of twelve grains of tar-
tar  emetic was followed  by bloody vomit-
ings, convulsions, and delirium.  M.  Vac-
quie has' recorded a case of acute  gastro-
peritonitis, made to terminate in gangrene,
and M. Barbier, two cases of inflamma-
tion of the stomach, exasperated and ren-
dered rapidly mortal, by the use of large
doses of this antimonial.  Too much cau-
tion, therefore, cannot  be exercised in  its
administration in diseases in which the
alimentary canal is implicated.
  e. Tartar emetic as a corrosive.   Tar-
tar  emetic, when applied in a solid state,
or in concentrated solution to the different
tissues, gives  rise to a violent inflamma-
tion ending in ulceration or corrosion of
the part.  When thus applied to the skin,
as by means of tartar emetic ointment, it
first produces vesicles,  which,  in the pro-
gress of the inflammation,  next become
pustules, and afterwards ulcere, more  or
less large and deep according to the sus-
ceptibility of the skin,  and the strength
and duration of  the  application.  It  is to
the therapeutic effects of this artificial cu-
taneous eruption, thus excited by the ex-
ternal application of tartar emetic, that
we  shall confine our remarks, under the
present head.
  The external application of tartar eme-
tic  appears  to have been first proposed as
a remedy by Dr. Bradley, in 1773, in a
paper detailing  its  efficacy  in rheumatic
affections, and published in  the Memoirs
of the Medical  Society  of London.  He
very  correctly describes the  pustules  as
resembling those produced by small-pox.
In  several of Dr. Bradley's cases, the
eruptions  were  not  confined  to the part
subjected to the  frictions, but  extended to
other and distant parts of the body; and
in one case the eruption was preceded by
restlessness, and a slight degree of nausea.
  No further  observations of importance
appeared on the external use of this anti- 
ANTIMONY.  (Therapeut.)                        63
monial, until January 1821, when Dr. Ro-
binson published a paper in the London
Medical Repository, on its curative effica-
cy in whooping cough, when employed in
the way of frictions on the region of the
stomach.  The next  contribution on the
subject was from the pen of the late Dr.
Jenner, dated in November  of the same
year,  in this highly important paper, the
Doctor, after sketching the  observations
of his predecessors  in the same field of in-
quiry, details his  success, more or  less
complete, with the use  of tartar emetic
ointment in mania,  hysteria, hypochondri-
asis, asthma, bronchitis,  hemoptysis, cho-
rea, chronic hepatitis complicated  with
pulmonary irritation, and some other dis-
eases. The external use of tartar emetic,
with a view to  its producing  artificial
eruptions, having been thus introduced to
the  notice of the  profession, under the
sanction of Jenner's  great name, it has
subsequently been  tried  in a number of
diseases, but particularly in pulmonary af-
fections, with more  or less success.   The
rules which should  govern its application,
according to the character of the morbid
action which it is intended to control, will
be detailed  under the head of the  indi-
vidual diseases in which, from experience,
its efficacy seems to be established.
  Besides  being used  as an ointment,
either in  frictions  or applied spread on
linen, tartar emetic, in order to  produce
its  eruptive effect  may be sprinkled on
the surface of some adhesive plaster, which
is then to be applied to the part intended
to be affected, previously shaved if covered
with hairs.  Of these several methods, the
plan by using adhesive  plaster gives the
least trouble, and is  preferable in maniacal
cases, in which frequently the patient will
not  submit  to  frictions; but  when  thus
used, the progress of the eruption is not
so easily watched, and, therefore, there is
more danger of  the  inflammation being
excessive, and terminating in deep ulcera-
tions difficult to heal.  When  a speedy ac-
tion is desired, as in tetanus or hydropho-
bia,  or when insusceptibility of the  skin
exists, it has been recommended to apply
cupping-glasses to the part either with or
without scarifications, before subjecting it
to the action of the tartar emetic.
  According to Dr. Robinson, the modus
operandi of tartar emetic, externally ap-
plied, is peculiar, and quite different  from
that of a blister, which only raises the
cuticle.  Dr. Jenner coincides in opinion
with Dr. Robinson  as to the peculiar ef-
fect of tartar emetic as  an external irri-
tant  By tartarized  antimony, Dr. Jenner
remarks, "we  can not only create vesi-
cles, but we can do more; we have at our
command an application which will at the
same time both vesicate, and produce  dis-
eased action on the skin itself,  by deeply
deranging its structure beneath the sur-
face.  This is probably one cause why the
sympathetic affection excited by cantha-
rides, and those changes produced by  tar-
tar emetic, are  very different"
  Metallic antimony.  M. Trousseau as-
serts, as the result of his experience, that
antimony, perfectly pure and porphyrized,
has an action almost as energetic as that
of tartar emetic.   He finds  it difficult to
explain this fact on account of the insolu-
bility of the metal; and though it may be
admitted that it is oxidized in the stomach,
still  the difficulty remains of explaining
why it is  more  active  than the oxides
themselves.
  Notwithstanding these positive asser-
tions of Trousseau, M. Rayer denies to
pure antimony  the possession of any ac-
tivity, and  asserts that he has given it in
doses of several drachms without produc-
ing any effect.   Perhaps the different re-
sults obtained by these experimenters may
be explained on  the  supposition, that M.
Rayer did not  use the metal in a porphy-
rized state.
  M. Trousseau states that he has exhi-
bited porphyrized metallic antimony with
advantage in peripneumony, articular rheu-
matism, and catarrh.  It may be given
in pills or  powder, mixed with magnesia
or prepared carbonate of lime, in  doses
varying from eight grains  to a drachm.
Triturated with lard,  in the proportion of
two parts of the metal to one of the unc-
tuous substance, it forms a preparation
which may be substituted for tartar eme-
tic ointment
  Prepared sulphuret of antimony. Syn.
Crude antimony.   This preparation  has
been used principally in scrofula, glandular
obstructions,  gout chronic  rheumatism,
and chronic diseases of the  skin.   Hufe-
land considered  it  applicable to  those
cases of scrofula in which, from the sus-
ceptibility of the stomach, the use of other
antimonials excites nausea, vomiting,  and
diarrhoea.  Guldbrand of Copenhagen has
published a paper on its good  effects in
gout and rheumatism, given every night
in the dose of half a drachm; but as infu-
sion of elder-flowers and purgatives were
used at the same time,  it  is difficult to
decide on the  degree of efficacy of  the
sulphuret.  It is, perhaps, in chronic  dis-
eases of the skin, that the good effects of
the prepared sulphuret  have been most 
 64                       ANTIMONY.

 prominently evinced; but even here Ray-
 er believes that  more is to be  attributed
 to the diet and rest which are usually en-
 joined at the same time, than to the anti-
 monial itself.
   The chief therapeutic effect of sulphu-
 ret of antimony is  supposed to  be  altera-
 tive; but,  according to Cullen,  it pro-
 duces diaphoresis, and in large doses nau-
 sea and even vomiting.  It is given in va-
 rious doses, from  a  few grains  up  to half
 an ounce or an ounce daily. The average
 dose is about twenty grains.  In the treat-
 ment of cutaneous  diseases, it  is usually
 exhibited in conjunction with  conium, dul-
 camara, or guaiacum.
   Sulphuret  of antimony enters into  the
 composition of a number of European  for-
 mulae, intended as antirheumatic and  an-
 tisyphilitic remedies; such as  the anti-
 rheumatic  powder of Kcempfer and  lo-
 zenges of Kunckel ;  and  the antisyphi-
 litic tisan of Feltz  and decoction of Ar-
 noult.   It is also  an ingredient  in  the
 English quack medicine  called Spilsbury's
 drops, in  which it  is formed into a tincture
 with  corrosive sublimate,  gentian root,
orange peel, and red saunders.
  There  are great objections to the use of
prepared  sulphuret of antimony as a medi-
cine, on account of its unequal operation,
which arises from two principal causes,—
the condition of the stomach, and the  va-
riable purity of the  medicine  itself.  If it
meet with acid in  the stomach, it operates
violently, even though pure;  but in point
of fact it is seldom so.   From the experi-
ments of Guibourt,  it has been  shown
that the  ordinary sulphuret of antimony
used in pharmacy, contains, on an average,
more than one per cent,  of sulphuret of
 arsenic.  It is on  account of the presence
of this impurity, that the decoction of the
antimonial sulphuret is much  more active
 than an equal quantity of it in substance;
 for the insoluble sulphuret of arsenic which
 it contains, becomes converted by the boil-
 ing heat, into the soluble  and eminently
 poisonous arsenious acid. These facts show
 that this antimonial  deserves  no confi-
 dence, and should be entirely  discarded
 from medical practice.
  Kermes Mineral.  Syn. Hydrosulphate
 of antimony.   This antimonial first came
 into vogue as a remedy in 1720, the secret
 of its preparation having been purchased
 in that year  by the French  government
 from a surgeon named La Ligerie.  This
 fact shows the high estimation in which
 it was originally held.
  The action of kermes on animals is far
 less energetic than  that of tartar emetic.
 (Therapeut.)

Two drachms of it placed in the cellular
tissue of a rabbit produced no appreciable
effect.   Taken in doses of from four to
eight grains by a healthy person, it some-
times gives rise to vomiting, at other times
to stools accompanied by a general feeling
of indisposition; but occasionally no effect
whatever is produced.
  Kermes mineral, according to the dose,
and  the circumstances under which it is
exhibited, is supposed to be capable of act-
ing  either as a diaphoretic,  expectorant,
cathartic, or emetic.  As a cathartic and
emetic, however, it is now seldom employ-
ed.  It has been principally used in bron-
chitis, pulmonary catarrh, and in the ad-
vanced  stages of peripneumonies, with a
view to its expectorant effect.  To produce
this  effect it is generally advised to  be
given in a dose so moderate as to  excite
neither nausea  nor  alvine  evacuations;
but Rayer contends that its so-called ex-
pectorant operation is never more  mani-
fest  than when it acts  in a decided man-
ner  on  the alimentary  canal;  and that
when it facilitates expectoration  in bron-
chitis, it does so by acting as a derivative
from the lungs to the  stomach and bowels.
  To test the value  of kermes adminis-
tered in small doses as an expectorant M.
Rayer  gave it, in grain doses, in a num-
ber of cases of pneumony, pulmonary ca-
tarrh, and phthisis,  at the hospital  Saint-
Antoine, and without any evident effect in
modifying the character of the pulmonary
secretion. This secretion was indeed found
constantly to change; but not more cer-
tainly during than without the use of the
remedy.
  Although denying the beneficial effects
of small doses of kermes in pulmonary af-
fections, Rayer is disposed  to admit  its
power  in lessening inflammation of the
bronchi, when given in doses  sufficiently
large, sensibly to irritate the stomach and
bowels.  In the beginning  of peripneu-
monies, the dose may be carried, according
to his  views,  to  20,  30, 60, or even  80
grains,  and often  without producing co-
licky pains, vomiting, or diarrhoea; but its
good effects in this disease are less  mark-
ed than when large doses of tartar emetic
are employed. When given in these large
doses, it may be considered as acting as a
contro-stimulant.
  Kermes mineral is sometimes exhibited,
combined  with opium,  as a  sudorific  in
chronic rheumatism; but its  effects  are
probably far inferior  to  those of Dover's
powder in the same affection.  Conjoined
with calomel, it was administered by Bar-
thez with success, in visceral obstructions. 
ANTIMONY.  (Therapeut.)
65
  The dose of kermes varies, according
to the intention in giving it and the length
of time it  is continued, from one or two
grains,  to  twenty, forty,  or even sixty
grains.   In doses of one or two grains, its
effect  is hardly appreciable; yet,  if we
may believe Rayer, it is capable in those
doses, when it does not produce vomiting,
of awakening latent inflammation of the
stomach and bowels.  In the amount of
five grains it often causes nausea and vo-
miting, but these  effects are by no means
constantly  produced.   The  late Dr. Dun-
can of Edinburgh states that he has given
ten grains  three times a day, often with-
out producing any appreciable effect; and
the still larger doses which are given, are
borne, in consequence  only of the influ-
ence of habit.
   The best  form  of  administration  of
kermes is suspended in mucilage; though
it may be given  in  pills  and lozenges.
When  exhibited  in  the  liquid  form,  it
sometimes  renders the expectoration red-
dish ; an appearance which might impose
upon the practitioner, if not aware of its
cause.
   The uncertainty which obtains in re-
gard to the dose of kermes mineral proba-
bly arises partly from the variable nature
of the  preparation, and partly  from the
state of the  stomach as to acidity.   The
golden sulphur and the precipitated sul-
phuret of antimony, both weaker prepara-
tions, are  often confounded  with kermes
mineral; while the preparation itself is
probably not uniform,  as obtained by dif-
ferent formulae. On the other hand, acids,
when contained in the stomach, render
the preparation far more active, by effect-
ing its solution.
    Golden  Sulphur of Antimony.   This
preparation,  which was more  anciently
known than the kermes, possesses, gene-
rally, the same properties, when adminis-
tered in double or triple the dose.  If it
possesses any peculiar property,  it is, ac-
cording to  Rayer, that of producing sweat
more  certainly than  the kermes.  It has
been recommended especially in chronic
diseases of the skin, chronic rheumatism,
 scrofula, and gout.
    Precipitated Sulphuret  of Antimony.
 This preparation, like the two last noticed,
 is diaphoretic,  cathartic,  or emetic,  ac-
 cording to the dose.  Like them also, it is
uncertain  as to strength,  and variable in
its effects, according  to the condition  of
the stomach as  to acidity.  Its dose may
be  considered  as intermediate  between
that of the kermes and of the golden sul-
phur; as it  contains  more sulphur than
the former, and less than the latter.  It is
seldom given alone, but generally in com-
bination with an equal quantity  of calo-
mel, and  twice its weight of guaiac, in
the form  of the compound  calomel pills
of the  British Colleges,  generally called
Plumrner's pill; as the  combination was
originally, at the recommendation of Dr.
Plummer, admitted into the Edinburgh
Pharmacopoeia.  These pills  are  used as
an alterative  in secondary syphilis, and in
cutaneous eruptions, especially those of a
syphilitic  character,  or  conjoined with
henbane  or hemlock in  chronic rheuma-
tism.   Five grains of the mass  contain
somewhat more than one grain, each, of
the precipitated sulphuret and of calomel.
   Butter of Antimony.  Syn. Chloride of
antimony ; Muriate of antimony.  This
preparation is only used as an escharotic,
being occasionally employed  to cauterize
poisoned wounds, such as those occurring
in dissecting, or occasioned  by the bites
of rabid animals or venomous serpents. It
is also sometimes  used to destroy warts,
vegetations, and carious bone.   It is the
most powerful caustic  employed by the
surgeons, and  hence  requires to be used
with the greatest caution.  It is very con-
veniently applied by means of a little roll
of lint, previously made to imbibe a por-
tion of the caustic.  As this escharotic is
liable to absorb moisture from the air, and
thus to become weaker,  it should be kept
in a well-stopped bottle.
   Butter  of antimony,  as an escharotic,
is seldom used in the United States; and
considering its  extreme activity, and the
difficulty  of limiting its operation to the
precise parts  intended to be destroyed, it
may well be  doubted whether its use  ma£
not in all cases be superseded by that of
other and more manageable caustics.
   Oxides of Antimony. These oxides, as
already stated, are the protoxide, and an-
timonious and antimonic acid. With them
may be associated the powder of Algaroth,
as the protoxide containing muriatic acid,
and diaphoretic antimony, as chiefly con-
sisting of antimonic acid.
   Trousseau asserts, generally, that the
three  oxides of antimony are those anti-
monials which act with the greatest ad-
 vantage as antiphlogistics and contro-sti-
mulants;  their dose  varying  from  six
grains for an  infant, to a quarter or half
an ounce for adults in  the twenty-four
hours.  These  statements,  however, are
deficient in  precision;  for  it can  hardly
be admitted that the three antimonial ox-
ides operate  on the system precisely alike,
and may  be given in the same dose.   On 
66
ANTIMONY.  (Therapeut.)
the contrary, we have good authority for
believing that while the protoxide is me-
dicinally efficacious,  the deutoxide (anti-
monious acid) is nearly inert, and the tri-
toxide (antimonic acid), eminently active.
Thus Rayer states that the antimonic
acid is  irritant emetic, and poisonous, its
dose varying from the tenth of a grain to
four grains.
  In  the different accounts given of the
therapeutic  action of antimony, it is fre-
quently stated that the  white oxide has
been  found  useful in particular forms of
disease.  Now no designation of an anti-
monial preparation could possibly be more
indefinite than this; for all the antimonial
oxides are,  under certain circumstances,
white. What adds to the confusion is that
the snow-white oxide obtained by burning
the metal, formerly called the argentine
flowers of antimony, is called by some
authors  the  protoxide, by others, the deu-
toxide ;  while the washed diaphoretic an-
timony, supposed to consist of the tritox-
ide, united with a small portion of potassa,
is denominated, in the French Codex, the
white oxide  of antimony !
  One doubt connected with this subject
however, has been removed by Thenard
and Berzelius, who  agree in considering
the oxide obtained during the combustion
of the  metal as really the  protoxide;
though certainly, we may add, in a differ-
ent state of aggregation from that of the
same  oxide, when obtained by means of
nitric acid  and  washing with water, as
mentioned under the chemical head.  In
the absence of more precise information,
we shall assume that the white oxide, ex-
perimented with by MM. Trousseau and
Bonnet, under the auspices of M. Reca-
mier, at the Hotel-Dieu, was the white
protoxide, probably obtained by the com-
bustion  of the metal.   In the mean time,
we shall not consider, in the present state
of our knowledge,  the antimonious  and
antimonic acids  as worthy of being  spe-
cially noticed as therapeutic agents.
  The  principal disease,  in which the
white oxide  was used at the  Hotel-Dieu,
was peripneumony. The plan pursued by
M. Trousseau was to commence with a
large dose  of the oxide, amounting  to a
drachm for women and youths, and  to a
drachm and  a half for adults and old men.
The next day, he increased the dose  one-
half, and continued the treatment  at  that
dose,  until  the  febrile  symptoms were
completely  dissipated,  or  for two days
longer.   Afterwards,  he diminished the
dose  one-fourth every second day; while,
in the mean time, the amount of food was
progressively increased.   During  conva-
lescence, the patient should not  take  the
oxide within the hour preceding or follow-
ing a meal.
  Since the particular attention of the pro-
fession has been called to the treatment of
peripneumony by the white oxide of anti-
mony, several French practitioners, among
whom are MM. Bouillaud, Andral, San-
son the elder,  and Martin Solon, have
tried the medicine, and borne testimony
to its good effects.  More recently (May
1834),  M. Finaz has published a  paper on
the same oxide, and adds his testimony in
favour  of its remarkable  efficacy  in  the
disease referred to.   This  practitioner
makes  an observation which supports  our
opinion that the white oxide of antimony,
intended as the  remedy in peripneumony,
is really the argentine flowers; for he re-
marks  that the medicine did not produce
uniform effects,  when obtained from differ-
ent apothecaries; but that his success was
constant, when  he used the  oxide pre-
pared by sublimation.
  Powder of Algaroth. Syn. Mercurius
vita;  Submuriate of antimony;  Nitro-
muriatic oxide of antimony. Oxychloride
of antimony.  The general sentiment of
chemists is  that this preparation  is  the
protoxide of antimony, containing a  varia-
ble  quantity of muriatic acid, or  chlorine.
Be this as it may, it is certain that  it  is a
compound, very variable in its effects, and,
therefore, entitled to no confidence.  In
the dose of from one  to four grains, it is
sometimes violently emetic; and in still
larger  doses, it is capable of producing
dangerous  consequences.   According to
several authorities, it sometimes  produces
salivation.  From its  active and variable
qualities, it ought never to be prescribed
as a substitute for the  protoxide; but this
oxide  should be obtained  either in  the
form of the argentine flowers, or, accord-
ing to the recommendation of Dr. Barker,
of Dublin, by precipitating a  solution of
tartar emetic by means of carbonate of
ammonia.
  Diaphoretic Antimony.  Syn. White ox-
ide of antimony of the French Codex. We
have already stated that this preparation,
more properly called  washed  diaphoretic
antimony, is considered to be a superanti-
moniate of potassa; but it may be doubted
whether an equal weight  of nitre, as di-
rected in the Codex formula, is  sufficient
to convert the whole of the antimony  into
antimonic acid.  Even when a larger  pro-
portion of nitre is  employed, Berzelius
states  that the  washed product contains
superantimonite, as well as superantimo- 
ANTIMONY.  (Therapeut.)
67
mate  of potassa.   M. Petroz, who ana-
lyzed this preparation at the request of
Laennec, also found it to contain antimo-
nite of potassa, this salt being present to
the extent of about half its weight; but
the different samples, which he  subjected
to analysis, were found to differ materially
in composition.
   M. Rayer reports that diaphoretic anti-
mony introduced  into the cellular tissue
of rabbits, produced no  particular  effect.
Given in doses of two  or three drachms to
pneumonic  patients, it caused no percepti-
ble  derangement of the digestive func-
tions. Laennec has carried the dose rapid-
 ly, in pneumonia, to four or five drachms,
 without producing any decided effect.  M.
 Rayer states, as the result of his experi-
 ence, that,  notwithstanding its name, this
 preparation, of all the  antimonials  pos-
sessing any activity,  is  least disposed to
 act as a sudorific.  From these facts, there-
 fore, it may be fairly inferred that diapho-
 retic  antimony is a  weak  and variable
 preparation, and should be banished from
 practice.  The name given to it in  the
 French Codex is altogether incorrect.
   Glass of Antimony.  This preparation
 is violently emetic and cathartic;  and,
 from the harshness and  danger attending
 its operation,  is entirely laid aside in mo-
 dern practice.  In order to mitigate its ef-
 fects, the early chemists  roasted it  with
 wax, whereby it  was converted into the
 preparation called cerated glass  of anti-
 mony.  In this form, the glass is divested
 in part of  its violence,  and was formerly
 given in doses of three or four  grains, in-
 creasing, as a cathartic and emetic.  The
 cerated glass was praised by Pringle and
 others as a remedy in dysentery and diar-
 rhoea ; but at present it has very properly
 gone out of use in those diseases.
    Crocus of Antimony.  At present, this
 preparation is  only  used in  veterinary
 medicine.
    Antimonial Powder.  Syn.  Oxide of
 antimony with phosphate of lime.  This
 powder is  deemed alterative, diaphoretic,
 purgative,  and emetic.   It is given in fe-
 vers, and in inflammatory affections gene-
 rally, with a view to its  diaphoretic effect.
 At the present day, however, it is much
 less employed than formerly.   According
 to  Dr. Cheyne (Dub.  Hosp. Reports,  I.
 1818.) it  is a useful remedy in hydroce-
 phalic and apoplectic cases.  During the
 existence of the precursory symptoms of
 apoplexy* such as sense of fullness of the
 head,  vertigo,  indistinct vision,  tinnitus
 aurium, &c, he  was in the habit of re-
 sorting to the long-continued use of anti-
monial powder, in doses of two grains at
bed-time, gradually increased until a sen-
sible effect was produced on the stomach,
bowels, and skin. Combined with calomel
and guaiac, it is sometimes given in cuta-
neous  diseases, and with  calomel, cam-
phor, and  opium, in acute rheumatism.
The addition of a little rhubarb to the pow-
der,  renders it according to Dr. Cheyne,
less apt to excite nausea.
  The  utmost  diversity of opinion  exists
among  practitioners  as to  the  remedial
value of antimonial powder. The late Dr.
Duncan characterized it, in whatever way
prepared, as " one of the best antimonials
we possess."  Dr. A. T. Thomson places
no confidence  in  its diaphoretic powers,
and believes that " every object for which
antimonial powder can be prescribed  is
more certainly  obtained from the employ-
ment of small doses of tartarized antimo-
ny."   Dr. Barker of Dublin is of opinion
that more  efficacy has been attributed  to
it than it  deserves.  Many other practi-
tioners deny the remedial activity of this
powder, and not a few contend  that it  is
absolutely  inert.
   Antimonial  powder,  on account of its
insolubility, must be given either in pow-
der or pill. The ordinary dose with a view
to produce diaphoresis, is from three  to
eight grains, repeated every third or fourth
hour, and assisted by free dilution employ-
ed in the intervals.  In  larger doses, it
operates as a purgative and emetic.   It is
remarkable,  however, to  what an extent
 this preparation can be given, in some in-
 stances, without producing any effect. Mr.
 Hawkins  gave it in drachm doses morn-
 ing and evening, without any obvious im-
 pression ;  and  even Dr. Duncan admits
 that he has given it in scruple and half-
 drachm doses, repeated  several times  a
 day, without inducing  vomiting or  purg-
 ing. Dr. Elliotson relates cases in which
 he gave from half a drachm to a drachm
 with  little  or no effect (Medico-Chir.
 Trans. XIII. 233.)
   Taking into view the conflicting state-
 ments of equally respectable practitioners,
 we  are forced to admit that the substance,
 called antimonial powder, is occasionally
 active and occasionally inert.  The bare
 fact of the great inequality of its  opera-
 tion, under apparently the same circum-
 stances, is a sufficient objection to its em-
 ployment ; for whether the inequality de-
 pends  upon the presence or absence  of
 acid in the stomach, its variable composi-
 tion, or both, still the objection  to its use
 is valid.   If it should be  found on further
 observation, that the different states of the 
68
ANTIMONY.  (Toxicol.)
stomach as to acidity is the principal cause
of its diversified effects, then we should
entertain but little hope of  its ever being
rendered a safe and valuable remedy; but
if its unequal operation  should prove to
depend upon its variable  composition, the
task will belong to the future pharmaceu-
tist to devise some precise mode of pre-
paring it, so as to produce a uniform pre-
paration,  corresponding  with the  active
form of the antimonial powder as now in use.
   It may not be deemed an unreasonable
conjecture, that, notwithstanding the  la-
bours of physicians and chemists, the an-
timonial  powder,  though intended as a
substitute for James's powder,  is by no
means identical with it.  The proprietor
of that nostrum, no doubt, intended to de-
ceive the public by the complicated  re-
ceipt which he deposited  in the British
Chancery, in  order to obtain his patent,
and therefore, no dependence can be placed
on it But when we compare certain ana-
lyses of James's powder with those of an-
timonial powder, we find considerable dif-
ferences ; as, for example, the presence in
the former of potassa,  which could not be
an ingredient in the latter.  Thus M. Pul-
ly, an Italian chemist, has  analyzed what
he alleges to be the true James's pow-
der, in which he found antimonic acid 7,
phosphate of lime 4, sulphate of potassa
4.5, free potassa, holding protoxide of an-
timony, 3.5—Total 19.  (Ann. de Chimie,
 LV.  77. An 1804.)   Dr.  Barker  sup-
poses  that  the powder analyzed  by M.
 Pully, though probably made by roasting
 the materials according to the specification
 of Dr. James's patent was not  subjected
 to washing. He is of this opinion, because
 some samples of genuine James's powder
 which he examined, contained scarcely a
 trace of adhering sulphate of potassa. (See
 James's Powder.)
   $ IV.   TOXICOLOGICAL  EFFECTS,  AND
 Tests.   Of all the  antimonial prepara-
 tions, butter of antimony and tartar emetic
 are the only ones which can be properly
 ranked as poisons.  The former, however,
 as already explained, acts as a caustic,
 and is not likely to be swallowed; and,
 therefore, it would be of no practical im-
 portance to treat of its poisonous proper-
 ties.  We  shall, accordingly, confine our
 remarks under this  head exclusively to
 tartar emetic.
    Symptoms caused by a  poisonous dose
 of tartar emetic.  Tartar  emetic, when
 taken in a poisonous dose (twenty grains
 and upwards), causes, in  different cases,
 excessive vomiting, spasmodic contraction
of the pharynx and oesophagus, difficulty
of swallowing, hiccup, ardent thirst, burn-
ing at the  stomach,  sharp pains in the
stomach  and bowels,  bilious, frothy, and
bloody stools, tenesmus,  suppression  of
urine, tendency to syncope, syncope, pros-
tration,  intermission, inequality, and con-
traction of the pulse, coldness of the skin,
sometimes intense  heat, difficulty  of re-
spiration, vertigo, loss of sense, convulsive
movements, very painful cramps of the
limbs, &c. &c.  Cases in which it has been
taken to a sufficient extent by man to
cause death are rare; for, in consequence
of the occurrence of vomiting,  the poison
seldom  remains long enough in  the  sto-
mach to produce fatal effects.   The influ-
ence  of vomiting is strikingly shown  by
the fact that Magendie found that dogs
could sometimes take half an ounce of
tartar emetic with impunity, if allowed to
vomit;  but that  if the gullet  was tied,
from four to eight grains would kill them
in a few hours.
   Post-mortem appearances.   According
to the experiments of Magendie on infe-
rior animals, the lesions produced by tar-
tar emetic consist principally in inflamma-
tion, more or less extensive, of the lungs,
and of the mucous membrane  of the ali-
mentary canal.  The post-mortem appear-
ances observed by Rayer  in his experi-
ments, were generally the same  as those
recorded by Magendie, with the exception
that he found no lesion of the lungs. (See
p. 54.)   When death occurs quickly, as
for example, in twenty-five minutes, from
tartar emetic applied to a wound, no trace
of inflammation is sometimes discoverable
 in any of the organs.  This fact is  impor-
 tant in medico-legal investigations.
   Dr. Charles A. Lee, in the  New-York
 Medical  and Physical  Journal for 1829,
 has reported a case of death from tartar
 emetic,  in a child of a few weeks old, who
 had swallowed about fifteen grains of the
 emetic salt  On dissection, the mucous
 coat  of the  stomach was  found red and
 softened.  Held  up to the light it was of
 a bright crimson colour.   The  stomach
 contained a small portion of slimy mucus,
 which appeared to consist of the mucous
 membrane softened.  The duodenum was
 of a deep-brown colour, almost livid, and
 contained the same kind of substance as
 the stomach. The inflammation  extended
 no further than the colon. The  vessels
 of the scalp, as well as of the brain, were
 full of blood, showing  a preternatural de-
 termination to the head.   The ventricles
 were half-filled with water, and there was 
ANTIMONY.  (Toxicol.)                          69
effusion between the pia mater and arach-
noid membranes.   The right side of the
heart  was distended with blood.
  Under the head of the post-mortem ap-
pearances after the  use  of tartar emetic,
it may be proper to mention that M. Gue-
rard, in the Revue Med. for Aug. 1831,
reports two instances  in which this sub-
stance, taken in large doses, produced pus-
tules  similar to those caused by its  appli-
cation to the skin,  and occupying a con-
siderable portion of the intestinal  canal.
In  these cases the stomach was healthy,
and the  intestines exhibited no sign of do-
thinenteritis.
   Treatment. The treatment of poisoning
by tartar emetic is very simple.  If vomit-
ing has  not occurred before the physician
arrives,  it should be induced, if  possible,
by tickling the throat, and causing the pa-
tient  to  swallow  large draughts of  warm
water. The administration of large quan-
tities of sweet oil will sometimes favour
vomiting, and may prove useful. While
these measures are being pursued, a strong
decoction of Peruvian bark, or of some other
astringent vegetable, should be prepared
and given freely to the patient. Until the
decoction is ready,  it will be proper to
give  the bark in powder, stirred up with
water.  If the bark be not at hand, the in-
terval consumed in procuring it should be
occupied by administering plentifully  a
strong decoction  of common tea.  These
different vegetables act  as antidotes in
consequence of their  containing tannin,
which decomposes the poison, and forms
with  its oxide the inert tannate of anti-
mony. According to Orfila, alkaline  sul-
phurets, which have been proposed as an-
tidotes, augment the irritation. When the
patient has vomited enough,  and  taken  a
sufficient quantity of bark; laudanum, to
quiet  irritation,  wdl generally  be  found
useful, administered either by the mouth
or by injection.   To combat the consecu-
tive inflammation, bleeding, both general
and local, demulcent  drinks, and  other
soothing and antiphlogistic remedies must
be resorted to.
   The efficacy of cinchona as an antidote
is attested by several examples of its good
effects.  M. Serres relates the case of a
man who swallowed half a drachm of tar-
tar emetic,  and who recovered under the
use of this antidote.  The symptoms pro-
duced were, burning pain in the stomach,
convulsive  tremors, impaired sensibility,
cold clamminess of the skin, hiccup, swell-
ing of the epigastrium,  but no vomiting.
Decoction of cinchona was freely given;
and almost  from the first moment of its
administration, the patient felt relief, and
began to sweat and purge. Next morning,
vomiting occurred,  and  for several days
signs of slight inflammation  of the sto-
mach existed. We may add that the dan-
ger in this case arose from the absence of
vomiting; for, as a general rule, the  in-
gestion of half a drachm of tartar emetic
would not endanger the  life of an adult,
if free vomiting occurred.   Another and
more striking case is related by Dr. Sau-
veton, of Lyons, in the sixth volume of
the Bulletin  des Sciences Medicales.   A
lady swallowed by mistake a  solution  of
sixty grains  of tartar  emetic.  She was
seen in ten  minutes  by her  physician,
and at that time, vomiting had not taken
place.  Tincture of bark was immediately
given in large doses, and the lady reco-
vered,  without having experienced any
unpleasant symptoms, except nausea and
slight colic.
  Tests for Tartar Emetic. Dr. Turner,
in a paper published in the Ed. Med. and
Surg. Journ.  XXVIII. 71,  has examined
with great care the effects of different re-
agents on a solution of this salt. The re-
sults of his experiments, as detailed  by
Christison, are as follows.
  1. Caustic potassa causes a white pre-
cipitate of protoxide of antimony in a tole-
rably concentrated solution. The first por-
tions of the test have  no effect, as they
serve merely  to neutralize the  excess  of
acid in the antimonial salt; and an excess
of the test redissolves the precipitate pre-
viously thrown down.
  2. Lime-water  throws down a white
precipitate, (a mixed tartrate of lime and
antimony,) and acts with somewhat greater
delicacy than caustic potassa.   It has  no
effect,  however, when the  solution con-
tains only half a grain to the ounce.
  3. Carbonate of potassa (salt of tartar)
acts with still greater delicacy, also throw-
ing down a white precipitate of protoxide.
It does not act, however, in solutions con-
taining only  a quarter  of a grain to the
ounce.
  4. Muriatic and sulphuric acids throw
down a white precipitate, and  redissolve
it when added in excess.  A large excess
of the  sulphuric acid is necessary for this
purpose. These tests have about the same
delicacy as the carbonate of potassa. The
precipitate which they throw down is a
submuriate or subsulphate of  antimony,
mixed with cream of tartar.
  5. Infusion of galls,  when  fresh and
strong, causes a dirty,  yellowish-white
precipitate of tannate of antimony; but it
is not a delicate test, as it will not act in 
70
ANTIMONY. (Toxicol.)
 solutions which contain much  less  than
 two grains to the ounce.
   6. Sulphuretted hydrogen is by far the
 best test for tartar emetic.  In a solution
 containing only an eighth of a grain to
 the  ounce, it produces an orange-red co-
 lour, which,  upon expelling the excess of
 the  gas by heat becomes an  orange-red
 precipitate of hydrated sesquisulphuret of
 antimony.  In stronger solutions, the pre-
 cipitate is thrown down at once.  The pe-
 culiar colour of this precipitate is in gene-
 ral sufficient for recognizing it;  but if an
 unwillingness  should be felt to rely  on
 this single mark, it may be further distin-
 guished by its solubility in a solution  of
 pure potassa, and by dissolving, with dis-
 engagement of sulphuretted hydrogen, in
 hot muriatic acid, forming a  solution  from
 which  a white curdy precipitate (powder
 of Algaroth) is thrown down by water.  It
 is readily distinguished from the sulphuret
 of arsenic, which is very soluble, with loss
 of colour, in  liquid ammonia; whUe the
 antimonial sulphuret is but sparingly solu-
 ble in the same alkali, without decoloration.
   In medico-legal investigations arising
 out  of  cases  in which poisoning is sus-
 pected  to have been  produced by tartar
 emetic,  the  salt will  exist either in the
 solid state,  or mixed with  organic  sub-
 stances, such as half-digested food, &c, as
 existing in the stomach.  In the solid state,
 tartar  emetic, upon  being  subjected  to
 heat decrepitates, gives off  white fumes,
 and  then chars.  If the heat be increased,
 the  oxide of antimony is reduced by the
 carbonaceous matter,  and little metallic
 globules, resembling  mercury in colour,
 will  be  found disseminated  through the
 mass.   According to Dr. Christison, the
 best way'to reduce tartar emetic is to  char
 it in a porcelain  vessel, or watch-glass,
and  then to  increase the heat till the
 charred  mass takes fire.  This method,
 however, is applicable to those cases  only
 in which a  considerable  portion of the
 emetic  salt is at the command  of the ex-
 perimenter.
   When the tartar emetic is mixed with
alimentary liquids, by which it is partially
or not at all decomposed, it is merely ne-
cessary, according  to  Orfila,  to subject
 the suspected liquid, after filtration, to the
action of the appropriate tests  for tartar
emetic, but especially  to a current of sul-
phuretted hydrogen, in order to decide on
the presence of the poisonous salt If, how-
ever, it has been entirely decomposed by
the alimentary matters with which it may
have come in contact he recommends that
the suspected matter should be dried with
charcoal and potassa, and then calcined in
a crucible, in order to bring the antimony
to the metallic state.  Sometimes,  how-
ever, he very correctly remarks, the quan-
tity of tartar emetic present is so small,
as not easily to admit of being detected by
this process.  In this case, he advises that
the product of the calcination be dissolved
in dilute aqua regia, which will have the
effect of oxidizing and dissolving the an-
timony; and  that the solution obtained,
after  having  been  freed from  excess  of
acid  by  evaporation and  filtered, be pre-
cipitated by a stream of sulphuretted hy-
drogen, in order to bring the antimony to
the state of sesquisulphuret
   For detecting tartar emetic when mixed
with  organic substances, Dr. Turner has
proposed  the following  method,  which,
with  Dr. Christison, we  greatly prefer
to that of Orfila.   The  substances are
first digested in water, acidulated with a
little  muriatic and tartaric acids;  the for-
mer acid to coagulate some organic  mat-
ters, the latter, to give complete solubility
to the antimony. This property of tartaric
acid depends upon the feet, ascertained by
Dr. Turner, that this acid dissolves all
precipitates  whatsoever,   formed  by re-
agents  with tartar  emetic,  except  that
caused  by sulphuretted hydrogen.  The
solution obtained, after having been filter-
ed, is subjected to a stream of sulphuretted
hydrogen,  "when the orange-red  sesqui-
sulphuret of antimony subsides, which pre-
serves its  characteristic  tint even when
deposited from coloured solutions.  It may
then be further  recognized by solution  in
hot muriatic  acid,  and  precipitation by
water."
   Thus it  appears that Orfila, Christi-
son, and Turner, among the best authori-
ties extant as toxicologists and chemists,
agree in considering sulphuretted hydro-
gen as  the best test for tartar emetic  in
solution.  They also coincide in viewing
the precipitate which it produces (the ses-
quisulphuret)  as  the  most  eligible  sub-
stance to be submitted to the process of
reduction, in order to obtain the antimony
in the metallic state.
   In giving evidence on trials, the medi-
cal jurist should not be content to rest his
statements solely on the indications of the
liquid tests.  The evidence  furnished by
these  tests is, indeed, often very satisfac-
tory, but still incomplete.  To  render it
complete, it is necessary that the poison
should be brought to  the  metallic state.
Hence it is that the mode of conducting
the process of reduction is  of such great
importance. 
ANTIMONY.  (Toxicol.)                            71
  Orfila recommends that the reduction
be conducted as follows:—If the quantity
of sulphuret  amounts to  several grains,
mix it  with charcoal and potassa (black
flux), and heat it  to redness in a Hessian
crucible.   The combined action of the al-
kali and  carbonaceous matter will bring
the sulphuret to  the metallic state.  If,
however, the operator has at his command
a very small portion only of the sulphuret
the use of the crucible must be dispensed
with, and the  following process of reduc-
tion substituted.   Heat the matter mixed
with black flux, in a  small glass tube, by
means  of a lamp with four wicks, aided
by  the blowpipe.
   Dr. Turner is of opinion that the above
processes of reduction by the aid of black
flux are very precarious, and recommends
as preferable the following process, which
is.sanctioned  by the  approbation  of  Dr.
Christison.   Place  the  dry sulphuret in
a  tube,  transmit  through it a  current
of  hydrogen,  and  as soon  as the atmo-
spheric air has been  displaced, so as to
prevent an explosion, heat the  sulphuret
by the flame of a spirit-lamp. The decom-
position of the sulphuret commences at a
temperature by no means elevated; but to
complete  it and fuse the  antimony,  the
glass should be made red-hot and kept at
that heat for five or  six minutes.  " The
sulphur is carried off in the form  of  sul-
phuretted hydrogen, and  the metallic an-
timony,  recognizable by  its  lustre, re-
mains.    The  metal  is principally found
where  the sulphuret lay;  but if the cur-
rent of gas, during the reduction, happens
to be rapid, it  causes, mechanically, a spu-
rious sublimation of antimony, which lines
part of the tube with  a thin film of metal.
When much organic matter is* mixed with
the sulphuret the metal is sometimes in-
distinctly seen.  In that  case it should be
dissolved in a few drops of nitro-muriatic
acid with heat, and precipitated by  wa-
ter:  it may  then  be redissolved by  tar-
taric acid, and again precipitated with its
characteristic tint by sulphuretted hydro-
gen." (Dr. Turner.  Elements  of Chem-
istry.   Fourth London ed. 1833.  p. 566.)
This process of reduction by Dr. Turner
is stated by Dr. Christison to be capable
of developing " antimony characteristical-
ly from only a tenth part of a grain of the
sulphuret"   The lustre  of the metal, to
be  distinctly seen, may require the aid of
a lens.   Orfila  characterizes  Dr. Tur-
ner's  process as  a good  one in the hands
of the chemist, but objects to  it as too dif-
ficult to be readily carried into effect by
the mere physician who is not accustomed
to manipulate.  This objection on the part
of Orfila does not strike us as being valid.
   The apparatus  employed by Dr. Tur-
ner,  in his  reduction-process above re-
ferred to,  is  represented in the following
cut taken from Dr. Christison's Treatise
on Poisons.
 A, the vessel with zinc and dilated sulphuric acid, the latter of
which nay be renewed by the funnel B. 6, a ball on the emerging
tube, to prevent the liquid thrown up by the effervescence from pass-
ing forward.  D, E, corks by which C and G are fitted into F, tbe
tube which contains the sulphuret at F.  G, the exit-tube for the sul-
phuretted hydrogen, playing into a vessel containing a solution of ace-
tate of lead.  When the hydrogen has passed long enough to expel
all the air, tbe spirit-lamp flame is applied at F; aDd when sulphu-
retted hydrogen is formed, tbe lead solution is blackened.  The figure
is one-sixth the size of the apparatus.
                      Franklin Bache.

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72                                   ANTIMONY.
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 sedative and febrifuge powers of Emetic Tartar.
 Edinburgh, 1819.
   Robinson.  On Chin-cough;  in Lond.  Med.
 Re pos. Jan. 1821.
   Jenner.  On the influence of artificial  erup-
 tions, in certain diseases, &c.; in Edinburgh Med.
 and Surg. Journ. XVIII. 593.  Nov. 1821. Copied
 into the Am.  Med. Recorder.  V. 684.
   Peschier.  Lettre au professeur Pictet  sur le
 traitement des fluxions de poitrine; in Biblioth.
 Univers. de Geneve. XX. 142.  (1822.)
   Peysson.  Recherches sur les moyens de rem-
 placer le quinquina dans le Irailement des flevres
 intermittentes, &c.; in Recueil de Mem. de  Med.
 et de Chir. Milit.  XI. 147.  (1822.)   See  also in
 Ann. de la Med. Phys. I. 230,349—Ibid. IV. 322,
 and  VIII. 446.
  Jourdain, (E. L.)  Mimoire sur Vemploi de la
 potion stibio-opiacie du docteur Peysson,  dans le
 traitement des flevres intermittentes et des mala-
 dies piriodique.i apyritiques; in Journ. Gen. de
 Med.  LXXXIV. 300, and LXXXV. 27.   Paris,
 1823.
  Sauveton.  Mim. sur les avanlages qu'on re-
 tire de I'emploi de la pommade  slibiie, &c.; in
 Journ.  Gen. de Med. LXXXVI. 315.  Rapport,
 &c., ibid. p. 341.  Paris, 1824.   Obs. sur un em-
 poisonnement par  le  tartre  imilique; in  ibid.
 XCI. 145.  Rapport de M. Gendrin, ibid. 149.
  Comte.  Sur I'emploi de I'imitique,  el sur
quelques autres points de doctrine et de pratique
mldicale; in Journ. Gen. de  Med.  LXXXVI1.
 145.  Paris, 1824.
  Gillot. Obs. de mid. pratique, (flevres interm.
traitees par la potion de Peysson); in  Journ.
Gen. de Med. LXXXIX. 338.  Rapport de M.
 Audouard, ibid. 345; Reclamat. de M. Peysson,
 ibid. XCI. 134.  Pans, 1824.
   Barre.  De faction de I'imitique sur I'icono-
 mie animale.   Paris,  1824.
   Tonelli.  Annotazioni medicn-praliche sui re-
 sultamenti conseguili d'all 'uso della pomata sti-
 biata;  in  Annah  d'Omodei. XXXI. 67.  Milan,
 1824.
   Bertrand.  Obs.  sur  I'emploi avantageur de
 I'imitique a Vextirieure dansplusicurs maladies;
 in Journ.  Gen. de Med. XC. 145.  Paris, 1825.
 Rapport, ibid. 168.
   Mastropasqua.   On the use of tartar emetic
 to denuded parts; in Obs. Med. di Napoli, Jan.
 1825, and in Bull, de Sc. Med.  VI. 93. Paris, 1825.
   Vaidy.  Efficacili du tartre stibii a grande dose
 dans le traitement des inflammations de poitrine;
 in Journ. Complementaire des Sc. Med.  XV.
 203.   Paris,
   Delagarde. Obs. sur I'emploi de I'imitique a
 haute dose, &c.; in Archives Gen. IV. 481.  Pa-
 ris, 1824.
   Creighton.  On the use of tartar emetic oint-
 ment in epilepsy;  in Transact, of Coll. of Physi-
 cians in Ireland. IV. 332.  Dublin, 1824.
   Auquetin.  Considiralions  sur I'emploi dutar-
 Ire imilique a haute dose; in Journ. Gen. XCIV.
 146.  Paris, 1826..
   Cartwright, (Saml. A.) Pneumonia Biliom,
 in Amer. Med. Recorder. X. 41.  Philada. 1826.
   Laennec.   Traiti de  Vauscultation  midiate.
 2d ed.  Paris, 1826. Translated by Forbes. JMew-
 York, 1830.   p. 254.
   Strambio.   Intorno il  modo di agere delle So-
 stanze emetiche, <fec.   Milan, 1826.
   Vacquie.  Considirations  cliniques et physio-
 logiques sur  I'emploi du tartre  stibii a hautes
 doses dans le traitement de la peripneumonie et du
 rhumatisme; in Mem. de la Soc. Med. d'emula-
 tion. IX. 307.  Paris, 1826.
   Orfila.  Traiti des Poisons.  Paris, 1826.
   Thexard.   Traiti de Chimie.  Paris, 1827:
   Blache.  Obs. pratiques recueillies a Vhbpital
 des enfans malades, &c.; in Archives Gen. XV.
 12.  Paris, 1827.
   Turner (Edw.)  On the detection of antimony
 in mixed fluids; in Edinburgh Med. and Sure.
 Journ.  XXVin. 71.   (1828.)
   Bayle, (A. L. J.) Bibliotheque de thirapeutume.
 1.198.  Reprint of the Memoirs of Rasori, Pes-
 chier,  Laennec, and extracts from some others.
 Paris, 1828.
   Orfila.  Sur les moyens de constater la pri-
 sence de I'antimoine, &-c, dans  un  milange de di-
 vers liquides; in Archives Gen. XVI. 85. Paris,
 1828.
   Paris.  Pharmacologia. 7th  ed. London, 1829.
   Lee,  (C. A.)  Case  of poisoning by tartar eme-
 tic; in  New-York Med. and Phys. Joum.  July,
 1829. p. 302.                  '
   Delpech.   De I'emploi de I'imitique  dans le
 traitement des inflammations, et de sa propriiti
 antiphlogistique; in Memorial des Hopitaux du
 Midi. I. 475, 531, 593.  Montpellier, 1829.
   Rayer and  Guibourt.  Art. Antimoine, m
 Diet, de Med. et de Chirurg. Prat.  Paris, 1829.
   Benaben.  Mimoire sur I'emploi de I'imitique
 a  haute dose dans le  traitement des fluxions de
 poitrine; in Revue Med.  IV. 5, and 337.  Paris,
 1829.
   Duncan, (Andrew.) The Edin. New Dispen-
satory, twelfth edition.  Edinburgh, 1830.
  Dance.  Mimoire sur I'emploi du tartre stibii
d haute dose dans le rhumatisme articulaire aigu;
in Archives Gen. XIX. 485, and XX. 5.  Paris,
1829.—Ibid. Sur I'emploi du tartre stibii d haute 
ANTIPATHY.
73
dose dans le traitement de la pneumonie; in same
Journal. XXVI. 5.  (1831.)
  Byrne, (C.)  On the  use of tartar emetic oint-
ment in chorea, &c.; in American Journ. Med.
Sc. V. 313.   Philada. 1830.
  Graves and Stokes.   Clinical Reports, &c,
in Dublin Hospital Reports. V. 51. Dublin, 1830.
Republished in Select Med.-Chirurg. Transac-
tions, Ed. by Dr. Hays.  1.335.  Philada. 1831.
  Findlay, (J. B.)  Cases illustrative of the bene-
ficial effects  of a combination of tartarized anti-
mony and opium in rheumatism; in North Amer.
Med. and Surg. Journ. X. 167.  Philada. 1830.
  Lucas, (J. R.)  Obs. on the use of tartar emetic
in certain states of the system; in Transylvania
Journ. of Med. III. 126.  Lexington, 1830.
   Barker,  (F.) and Montgomery, (W. F.)  Ob-
servations on the Dublin Pharmacopoeia.  Dublin,
1830.
   Berzelius.  Traiti de Chimie.  Vol. II. III.
and IV.  Paris, 1830-31.
   Bricheteau. Obs. recueiUies a Vhbpilal Necker
pendant les  neuf derniers mois de 1831; in Ar-
chives Gen.  XXX. 211.
  • Spence.   Obs. on the treatment of mania and
delirium tremens by large doses of tartar emetic;
in  Edinburgh  Med. and  Surg. Journ. XXXVI.
112. (1831.)
  Teallier. Mimoire sur I'emploi de I'imitique
a haute dose dans la  piripneumonie,  et dans
quelques aulres maladies; in Joum. Gen. CXI. 10
Paris, 1830.—Ibid. Sur I'emploi du tartre stibii
a haute dose dans le traitement de la pneumonie;
in Archives Gen. XXVI. 5.   Paris, 1831.
  Chapman.  Elements of Therapeutics and Ma-
teria Medica. Sixth ed.  Philada. 1831.
   Teallier, (P. J. S.)  Dm tartre stibii et de son
emploi dans les maladies.  Paris, 1832.
   Christison.  Treatise on  poisons. 2d ed. p.
 425.  Edinburgh, 1832.
   Turner, (Edw.) Elements of Chemistry. 4th
 ed.  London, 1833.
   Luroth.   Des effets du tartre stibii employi
tant d I'intirieur que selon la mithode endermique;
in Gazette Medicale. I. 209.   Paris, 1833.
   Patin. Mimoire sur I'emploi des antimoniaux
insolvbles dans le traitement de la piripneumonie;
in ibid. p. 441.
  Trousseau and Orfila.   Art. Anlimoine, in
Diet, de Med. 2d. ed.  Paris, 1833.
  Finaz. De I'oxide blanc d'antimoine dans la
pneumonie; in Revue Med. March, 1834. p. 209.
  Franc, (M. J.)  De I'emploi du tartre stibii a
hautes  doses, contre les lisions traumatiques.
Montpellier, 1834.
  Eberle.   A Treatise of the  Materia Medica
and Therapeutics.  Fourth ed.  Philada. 1834.
  Wood and Bache.  The Dispensatory of the
United States of America. 2d ed. Philada. 1834.
                                  I.H.

   ANTIPATHY.  (From  avti, against,
and rtaSoi,  feeling.)   avi'irta^, Gr.; An-
tipathia, Lat.;  Antipathie, aversion, Fr.
Involuntary aversion or  repugnance, na-
tural or acquired, to any object.  To all
the  senses,  internal as well as external,
certain  excitants are pleasurable   and
others painful;  the former are  the  source
of the appetences (q. v.), the latter of the
antipathies.  Every living being appears
to be endowed with a love of life,  and to
experience a desire for those objects which
  VOL. II.          7
tend to the preservation of their existence,
and a repugnance to whatever  is calcu-
lated to destroy it.   This latter may be
considered  as a natural, instinctive  anti-
pathy.   The  caprices  of individuals, or
some associations, give rise to a number
of antipathies, which, as  their origin de-
notes, are acquired.   Anomalies of sensi-
bility—a peculiar mode of affectability of
the  organism,  idiosyncrasy (q.  v.),—and
real diseases of the organs,  the  instru-
ments of the sensations, furnish not less
fruitful sources of these  aversions,  some
of which are of the most singular char-
acter.
  Numerous  examples of these antipa-
thies are recorded  in  the annals of our
science,  and there are probably few  prac-
titioners whose own experience has not
furnished instances of them.  Deusingius
is said to  have known a man who could
not  look upon the  head  of a hog with-
out  fainting,  and  who could eat  of  it
without  disgust when the ears  were re-
moved. (Diet, des Sc. Med. II. 202.). We
are acquainted with  a gentleman who has
an  antipathy to the sight of a spider, or
even a  picture of one; and also with a
lady who has an aversion  to the sight of a
mouse, and this is equally the case whe-
ther the animal be  alive or dead.  Ama-
tus Lusitanus quotes the case of a monk
in whom the odour of a rose caused faint-
ing, and who was compelled, during the
season of this flower, to confine himself to
his cell.  (Ibid.) Zimmermann has furnish-
ed us with  the case  of  an individual who
was always thrown into convulsions by the
rustling of silk, and we ourselves knew a
person who had the greatest horror of the
feel of velvet. The  anatomist Gavard, it
is said, could not eat apples without expe-
riencing convulsions, which  continued so
long as the fruit remained in his  stomach;
and three  individuals have come  under
our own observation, in whom the taste or
odour  of wine excited extreme nausea.
The loathing experienced at the thoughts
of food which has caused indigestion, is
familiar  to  every one.
  Without pretending that we should  be
guided by  the aversions,  of which  preg-
nant women and chlorotic girls furnish so
many examples, it is not  the less certain
that great  utility may be  derived,  in the
diagnosis and treatment of diseases, from
attention to  the  antipathies;  but  it is
necessary carefully  to  distinguish  those
which result  from the  prejudices of the
patient or   of his attendants, from  those
which are  the expression of real sensa-
tions.  The presence or absence of a re- 
74                    ANTIPERIOD.—ANTIPHLOGIST.
pugnance to hot drinks may serve to dis-
tinguish gastritis from ileitis;  and the
aversion to particular descriptions or every
kind  of food in certain diseases, is  often
the expression of a genuine sensation, the
language of the suffering organs which it
is the duty of the practitioner to respect.
                             I.  Hays.
   ANTIPERIODICS.  This epithet has
been  introduced  into  medical language,
within a few years,  by  the French, to de-
signate those therapeutic agents which
possess the property of  preventing the re-
turn  of the paroxysms  of intermittent or
periodic diseases.   The agents to which
this property has been  assigned, are ex-
ceedingly numerous.  Those admitted by
general consent, to enjoy it, in the highest
degree, and to be  most constant in  their
operation, are cinchona and its alkaloids.
It is also possessed, though  in a less de-
gree,  by all the  different vegetable sub-
stances having  analogous physical and
physiological properties to the cinchona,
and particularly  characterized  by great
bitterness, as the  barks of the dog-wood,
willow, oak, &c, gentian, columba, quas-
sia, wormwood, absinth, angustura, leaves
of the holly, &c.: also by many mineral
tonics and  astringents, as the  sub-car-
bonate,  Prussiate, and sulphate of iron,
sulphate of alumina, oxide of zinc and
subnitrate  of bismuth,  &c,  and various
other  agents,  as  the  arsenical  and an-
timonial preparations,  emetics,  purga-
tives,  bleeding, epispastics,   ligature  to
the limbs,   shower-baths,  strong mental
emotions, &c. &c.
  From the above enumeration, it  must
be manifest that  there  exists no analogy
between the evident properties  of these
agents, some of which indeed are charac-
terized by entirely opposite qualities, and
the circumstances under which they prove
effectual, are, moreover, infinitely varied;
hence it is not in any common property
that we are to seek for an explanation  of
their  modus operandi.   This must be de-
rived  from a knowledge of the nature of
periodic diseases and of the modifications
in the organism  induced  by their reme-
dies, questions which this  is not the place
to discuss; and we must therefore refer to
the articles Periodicity, Intermittent fe-
ver, Cinchona, &c,  where  they will  be
fully  considered.   It may be expected,
however, that we  should  briefly state  in
this place the general conclusions on this
subject, and we shall accordingly attempt
the task.
  The attraction to itself,  by some organ
or tissue, the seat of irritation—the con-
centration on it—of an undue portion of
the sanguine fluid, is an essential element
of the paroxysm of all intermittent dis-
eases, as of all irritations.   The preven-
tion of the  occurrence of this congestion
is then to ward off the access of the  pa-
roxysm.   This, it appears to us, may be
accomplished  in  three ways; 1. by those
agents which  cause a sedation in the  or-
gan or tissue the' seat of the irritation, and
thus destroy the  moving power  produc-
tive of the  afflux; 2.  by those which  di-
vert the current to some distant part, by
exciting either another and temporary ir-
ritation or by  giving a centrifugal direc-
tion to the circulation; and 3. by those
remedies which excite the general capil-
lary circulation,  or,  as suggested by our
ingenious colleague, Dr. Jackson, which
" impart force  and stability to the actions
of the capillary and parenchymatous struc-
ture and circulation;"  thus enabling them
to refuse to yield their fluids at  the de-
mand of the irritated tissue.   The agents
which act in the first  mode  are the nar-
cotics, cold, local depletion, &c.;  in the
second, epispastics,  purgatives, ligatures
to the limbs,  emetics, &c.;  and  in the
third,  cinchona  and its  congeners, the
mineral tonics, &c.           I. Hays.
  ANTIPHLOGISTICS.   (From am,
against, and yxtyu,, I burn.)   in its strict
etymological meaning, this term  desig-
nates those means directly calculated to
repress and abate  inflammation.  It  is,
however, very frequently employed in a
more  extended meaning.   It is  applied
often to all the means that enter into the
treatment of inflammations. But the treat-
ment for inflammation may be, and in re-
ality# is, exceedingly diversified, and con-
sists of the production of varied and even
opposite  phenomena.   Depletion, emol-
lients, sedatives, stimulant and  exciting
evacuants, and revulsives, are all brought
into operation.  Because the cure of  in-
flammation  is  the  consequence  of this
combined action of different  agents, they
must not therefore all be characterized by
the same general term. The language of
science  should be  precise,   and  names
should, as much as possible, be expressive
of positive phenomena  or characters. The
term antiphlogistics should  then  be  re-
stricted to those agents whose immediate
and  direct action on a living tissue, is to
allay or abate its vital activity and reac-
tion ; to diminish  the force of its vital phe-
nomena, and thus oppose those conditions
essential to the  existence of the pheno-
mena of inflammation.  The remedies pos-
sessing these characters and properties are, 
ANTIRRHIN.—ANTISCORB.                       75
    1. Sanguine depletion, both general and
 topical, when duly employed and properly
 applied;
    2. The  classes of demulcents,  emol-
 lients, temperants, with cooling aqueous
 drinks;
    3. Baths, general or local, fomentations,
 and poultices;
    4. Cold,  adapted in  its  degree to the
 animal temperature and force of vital ac-
 tivity ;
    5.  An exact,  mild,  and  limited  diet,
 from which are excluded all stimulant, ex-
 citing  and heating articles of food and
  drink.   It is often named  antiphlogistic
  diet or regimen.
    The whole combined together form the
  antiphlogistic treatment-
    Emetics, purgatives, and other evacu-
  ants have been placed amongst the anti-
  phlogistics.  Nothing can  be more  erro-
  neous.  Their positive and direct action is
  the opposite of that produced by the anti-
  phlogistics, and it is only secondarily that
  they exert such an influence.  They first
  excite the  tissue on which they act, as a
  consequence  of  which secretion  ensues.
  But,  if this does not occur, as  often hap-
  pens, a phlogosis or inflammation then re-
  sults or is aggravated if previously  exist-
  ing from the intensity of their unrelieved
  irritation. (See Inflammation.)
                            S. Jackson.
     ANTIRRHINUM.     Snap-Dragon,
  Toad-Flax.  Linaire, Fr.
     Sex. Syst.   Didynamia  angiospermia.
  Nat.  Ord.  Scrophularineae.
    Gen. Ch.  Calyx five-parted; the  lower
• segments remote.   Corolla calcarate, rin-
  gent,  orifice  closed by the prominent pa-
  late.    Capsules  ovate,  two-celled,  two-
  valved, bursting at the  summit with three
  to five reflected dentures,  a stapediform,
  styliferous arch remaining between either
  aperture.  Goertner.
    Almost all the species of plants belong-
  ing to the natural order Scrophularineje
  are possessed of somewhat similar proper-
  ties,  being acrid  and  poisonous,  which
  qualities are strongly developed in the ge-
  nus under consideration, several species
  of which are common in the United States.
  It should  be  noticed that by the late im-
  provements in botany all the species with
  a calcarate corolla have been formed into
 a separate genus under the  name of  Lina-
 ria.   The most common and most  gene-
 rally used of these plants,  is the
    A. linaria. [Linaria vulgaris.]  Toad-
 Flax, Ransted-Wked, &c. Linaire, Fr.;
 Leinkraut, Germ.   Sp. Ch.  Stem erect;
 leaves linear-lanceolate, scattered, crowd-
ed,  spikes terminal; flowers imbricate;
calyx smooth, shorter than the spur. Beck.
This well-known plant, which is by far too
abundantly found in all parts of the United
States,  is not indigenous, though it ap-
pears to have been introduced at a very
early period after the first settlement.  It
is usually found in barren fields, pastures
and  road-sides, where its yellow flowers
are  very conspicuous from  July to  Sep-
tember.  It is  perennial  and extremely
difficult to eradicate.  It has a strong un-
pleasant virous  smell, somewhat  resem-
bling that of the narcotic plants.  Its  taste
is rather bitter and  nauseous.   At  one
time, it was in high repute as a purgative,
but more especially as a diuretic, and the
older writers on the materia medica ap-
pear to have had the  greatest confidence
in its powers, to fulfil not only those  indi-
cations but many others.  At the present
day, however, it is  seldom used except as
an external application, particularly in the
treatment  of  hemorrhoidal  tumours;  of
its  efficacy for this purpose, there is am-
ple testimony [Haller, Curtis, &c]  ; and
from our own  experience of its good ef-
fects in the relief of the pain and irrita-
tion attendant on this complaint, we are
inclined to think highly of its powers.
The part  used is the  expressed juice,
which may be  employed either as  a fo-
mentation, or mixed with a cataplasm. It
is also made into an ointment, which has
attained some celebrity in domestic  prac-
tice not only in  the cure of hemorrhoids,
but  also in tetter  and other diseases of
the skin.
  The A. cymbalaria, ivy-leaved toad-flax,
which is a native of Europe, and, accord-
ing to Dr.  Hamilton, is also found in In-
dia, has been employed in medicine as a
vulnerary.  Merat and De Lens are of
opinion that it does not possess  the  acrid
and poisonous properties of the A. linaria,
but  is allied in its therapeutic  effects to
the antiscorbutic vegetables. Dr. Hamil-
ton states that he was informed  by a Hin-
doo physician, that the dry plant was given
in India in combination with sugar twice
daily in diabetes.
  The seeds  of another species, the A.
majus or greater snap-dragon,  furnish a
large proportion of a bland oil, which forms
an  excellent  substitute for that of the
olive.                 R. E. Griffith.
   ANTISCORBUTIC.    (From  anti,
against, and scorbutus,  scurvy.)  Under
this term is strictly included every mea-
sure suitable to the cure of scurvy; but
formerly it was  especially applied to the
cruciferous and alliaceous plants, because 
76                               ANTISEPTIC.
they were believed to possess specific vir-
tues against the disease.  This last appli-
cation of the term is,  however, exceed-
ingly objectionable, since these plants are
not only far from being  the only remedies
for  the complaint, but they are in many
cases utterly useless and even contraindi-
cated.   In the article Scurvy  the thera-
peutic agents which have  attained repu-
tation as antiscorbutics will naturally pre-
sent themselves for consideration, and to
avoid repetition we will merely refer to
that article.                      I. H.
  ANTISEPTIC.  (From am,  against,
and a^rttoi, putrid.)  According to its ety-
mology and in its most  extensive signifi-
cation,  this term  is applicable to every
means capable of preventing putrefaction
either in  dead or  living organic  matter.
The putrefaction of dead matter is hin-
dered  by  various physical agents which
defend  it from the action  of  influences
favourable to its decomposition; but as a
consideration of them cannot be conveni-
ently separated from  the examination of
the changes which take place during the
putrefactive process and of the  conditions
which  favour  those  changes,  we  must
refer  for an  exposition  of this  subject to
the articles Putrefaction and Gangrene.
There is, however, a more restricted sig-
nification in which the term  antiseptic
has been used,  and which appears to de-
mand a brief explanation here.
  During the reign of the humoral patho-
logy,  various diseases were  ascribed to a
general putrescency or  septic state of the
fluids  and solids;  and the remedies sup-
posed to be curative of this condition were
termed antiseptics. With the downfall of
humoralism, the belief in the existence of
such a state was abandoned, and the term
antiseptic in this sense was banished from
the vocabulary of the solidists.  But there
is probably  no hypothesis, however ab-
surd, which does not contain at least some
portion of truth;  and  humoralism, with
all  its extravagances  and fictions,  em-
braced propositions not wholly  destitute
of foundation, and which ought not to be
allowed to perish in the ruins of the doc-
trine.  That a general putrescency of the
living organism can  take  place,  has un-
questionably never been proved, and there-
fore,  in sound  philosophy, cannot be ad-
mitted; but  that in certain diseases the
vitality of the solids and  fluids is dimin-
ished—that there  exists in these parts, if
not a  tendency to putrefaction, at least a
diminished ability to  resist the influence
of physical laws tending to their decom-
position, can scarcely be denied; and the
remedies employed for the removal of this
condition seem justly entitled to the epi-
thet antiseptic.
  If any portion of the  apparatus  of he-
matosis  be  incapable  of performing its
functions, the blood cannot be perfectly
elaborated, and must be deficient in some
of its constituents.  Will not then its vital
force, as well as that of the solids formed
from it,  be  lessened, and their ability to
resist the influence of chemical laws be
equally diminished 1
  The alimentary canal sometimes has its
vital forces  so depressed, as to lose, to a
great extent, its power over its contents,
which  putrefy, and the  most fetid gases
and products are generated.  Does not
the contact  of  these  products  with the
intestinal mucous  membrane,  and  still
more  their  absorption or imbibition into
the system,  aggravate extremely the ex-
isting or create new disorder ]    '
  If these questions be solved in the af-
firmative, it would seem to follow that the
solidists have been too exclusive in abol-
ishing from  the  materia medica the class
antiseptics.   The agents adapted  to the
relief of the conditions  of the  organism
adverted to, are  not  only those agents
which directly excite the vital energy, as
stimulants and  tonics,  but others  which
equally deserve  the title  of antiseptic, as
the acids and  some of  their salts, the
chlorides, creosote, &c, though their pre-
cise mode of action is not so well deter-
mined. To us it seems probable that these
last produce their beneficial effects some-
times by furnishing to the organism cer-
tain of its elements which are deficient,4
in  consequence of the  incompetency to
perform their- functions, of one or more of
the proper organs of supply; at others, by
preventing  the  decomposition  of foreign
matters within the organism, &c. Be their
modus operandi, however, what it may,
the utility of these agents is sanctioned,
by their being administered, at times, even
by those who are most vehement in their
denunciations of the possibility of the ex-
istence of a septic state in the economy.
M. Chomel  appears to  rely principally
upon chloride of lime or soda in the treat-
ment of some of the low forms  of typhus
fever.   Dr.  Stevens has adduced  strong
testimony to the  efficacy of the  neutral
salts in malignant yellow fever, and vari-
ous facts recently observed  hold out the
belief that advantage may be derived from
creosote in   some of the  cases we have
been considering.  That the acids are often 
ANTISPASMODICS.                           77
productive  of the best effects in the de-
pressed states of the  system connected
with scurvy, is universally conceded.
  The  precise indications  which  these
agents are capable of fulfilling,  and the
circumstances which should guide  us in
their administration, will be more properly
considered in the special articles on these
agents and on the diseases in which they
are employed. Our only object at present
is to throw out a few hints, in the hope of
exciting attention to the subject; as we
are fully convinced that an investigation
will lead to useful results.   At the  same
time that we admit  the solidists have been
too  exclusive  in their views, we must be
permitted to disclaim all adhesion to the
old  humoral pathology—a doctrine  too
monstrous  and absurd, in its details, to be
for a moment entertained by any one whose
mind is not utterly benighted.  I. Hays.
   ANTISPASMODICS.   (From   arte,
against, and  onaaua, spasm.)  Medicines
calculated  to  relieve or prevent spasm.
They  operate  either  by  removing  the
cause  of the affection, or by producing in
the nervous system, an action or condition
incompatible with that which they are in-
tended to supplant.   As the causes of
spasm are various,  and its character ex-
ceedingly  protean,  the remedies are nu-
merous, and without any such community
of sensible or physiological properties as
might  entitle them to the rank of a dis-
tinct class of medicines.  A rapid view of
the  means which may be employed,  under
various circumstances, for the production
of an antispasmodic effect, will afford am-
ple  evidence  of the correctness of this
statement.
   The remedies addressed to the  cause
of the  complaint, must obviously vary with
the  cause.   When the spasm, as is proba-
bly  the case in most  instances,  depends
upon  inflammation  or an  irritation ap-
proaching  to inflammation, at the origin
or in the course  of  the nerves which sup-
ply the affected muscles, or in the muscles
themselves, it is plain that antiphlogistic
measures will be the most efficient. Hence
general and local bleeding, cathartics, ex-
ternal revulsives, and low diet, are often
excellent antispasmodics. But involuntary
muscular contractions often originate in a
state of debility, and are relieved by means
calculated to impart vigour to the system.
Under these circumstances, the diffusible
stimulants and tonics are the best anti-
spasmodics, the former being applicable to
cases of considerable and sudden debility,
the latter to those  of longer continuance
and  less prostration.
                  7*
  Of the  remedies which  relieve spasm
by acting  directly upon the nervous sys-
tem, some produce the effect by diminish-
ing the susceptibility of the nerves, and
thus rendering them insensible to those
impressions which ordinarily throw them
into more or less violent commotion.   In
this way,  in part at least,  narcotic medi-
cines act as antispasmodics.  Others ope-
rate by changing the direction or charac-
ter  of the  morbid nervous action.   What-
ever tends to induce and sustain a flow of
nervous energy to organs remote from the
part affected,  may relieve  spasm.   The
remedies capable of producing this effect
scarcely admit of enumeration; as there
is not a substance having  any medicinal
power, unless it be purely sedative, which
may not be made to exalt the nervous ac-
tion of some particular organ or system
of organs, and thus to draw off irritation
from some other part in which it may ex-
ist.  It is probably in this way that emetics
and nauseating substances  often prove so
efficacious in the relaxation of spasm, re-
lieving  distant  organs  by  concentrating
irritation in the  stomach.   But there are
also medicines which prove antispasmodic
by i peculiar influence over the  nervous
system, wholly  independent of any nar-
cotic power, and not explicable upon the
mere principle of revulsion.  The mode
in which such medicines operate cannot
be precisely understood, so  long as we are
ignorant of the nature of nervous action.
We see,  however,  effects produced  by
many of them so analogous as to entitle
them to be  classified together, and so dif-
ferent as a whole from the  effects of other
medicines  as to justify their arrangement
into a distinct group.   As, among these
effects, the relaxation of spasm is perhaps
the most  prominent, and that for which
the medicines are most frequently pre-
scribed, the class has in many treatises on
Materia Medica received the name of an-
tispasmodics; and it  is to  these that the
term is usually restricted in ordinary me-
dical language.   By  an  antispasmodic,
therefore, in this  sense, is  not meant any
medicine which is capable  of relaxing in-
voluntary and unhealthy  muscular  con-
traction,  but  merely an individual  of a
certain class of medicines, among the  ef-
fects of which the relief of spasmodic ac-
tion is one of the most observable and im-
portant.
  From what has been said, it will be per-
ceived, that the simple power of relieving
spasm cannot serve  as the basis of a dis-
tinct class of medicines; but that a na-
tural group exists, possessing  this among 
78
ANTISPASM.—ANUS.
other powers, to which the name of anti-
spasmodics has by many authors been ex-
clusively applied as the most convenient
The nomenclature is unfortunate, as it is
founded upon  an effect resulting  from a
great variety of remedies besides those in-
cluded in the class, and may therefore lead
to erroneous notions.  The term nervine
might perhaps be considered more appro-
priate; as  it expresses the main  peculi-
arity of the medicines, namely, their pre-
ferable direction to  the  general nervous
system, without any strong tendency,  as
in the instance  of the narcotics, to operate
especially upon the brain.  To this distinct
class of antispasmodics, the remainder of
the observations, under the present head,
will be confined.
   These medicines, for  the  most  part,
have a strong and disagreeable odour and
taste, and owe their virtues to a volatile
principle.   In  their operation upon the
system, they excite,  to a  greater  or less
extent,  the heart and arteries, increase
animal heat, promote usually one or more
of the secretions,  and  exalt the nervous
energy  in  general,  without  necessarily
producing,  either as  a  primary or second-
ary effect,  intoxication, delirium,  or stu-
por.   As remedies,  they  not  only allay
spasm, but  are  useful also in other disor-
dered operations of  the  nervous system,
and are frequently given to cheer the lan-
guid or depressed spirits, to quiet restless-
ness, to relieve morbid vigilance, and to
calm those  diversified nervous irregulari-
ties  which are grouped  together under
the name of hysteria.  Their particular
therapeutical application  will  be  treated
of under the  head  of the several sub-
stances individually  which  compose the
class.  It may  be proper,  however, in the
present place, to observe,  that  caution is
always necessary  in their use, when the
nervous affection depends upon or  is com-
plicated with acute local inflammation, or
a plethoric  state of the system.
   The antispasmodics most employed are
musk and  castor from the animal king-
dom ; assafetida and other fetid gum resins,
garlic, and valerian, from the vegetable
kingdom;  and the oil  of  amber, and cer-
tain ethereal  and ammoniacal prepara-
tions, the products of chemical processes.
The Symplocarpus foetidus has also anti-
spasmodic properties; and the empyreu-
matic oils resulting  from the destructive
distillation of animal substances, together
with various bituminous liquids, have been
supposed to be similarly endowed, though
at present discarded from practice. Seve-
ral of the narcotics  add  proper antispas-
modic powers to those by which they are
characterized as a class;  and are  often
effectual  in  relieving  spasm  and  other
nervous disorders,  in doses insufficient to
produce  their narcotic effects.  Such is
particularly the case with camphor and
opium.   Some of the medicines  usually
ranked among the tonics appear to  exer-
cise an influence over the nervous  system,
which renders them highly useful in cer-
tain chronic spasmodic and nervous disor-
ders,  in which there  is no reason to be-
lieve  that the complaint is connected with
debility, and  in which, therefore, their ac-
tion is  independent  of the mere  tonic
power.   Examples of this kind we  have
in Peruvian bark, and the various metallic
preparations  employed  in  the  treatment
of  neuralgic and  spasmodic  affections.
These seem to bear to the more exciting
antispasmodics the same relation that the
pure  tonics bear to the simple diffusible
stimulants.  They superadd a peculiar in-
fluence upon the animal functions to that
which they exercise upon the organic life,
and thus become susceptible of an extent
of useful application far beyond that of the
tonics in which  these powers are not con-
joined.                Geo. B. Wood.
   ANTITHENAR.  (From avn, against,
and dtvae, the palm of the hand or  foot.)
A name  given by Riolan and Winslow
to a  portion  of the  short flexor  of the
thumb, and to a  part of the oblique abduc-
tor of the great toe.              I.  H.
   ANTITRAGUS.  (From avth against,
and *eoy°s, the tragus.) A small, flattened,
conical eminence, situated posteriorly and
opposite to the tragus, and below the anti-
helix.                            I.  H.
   ANTRUM.   (From avteov,  a cavern.)
This term is  applied to certain  cavities in
the bones.
   Antrum Highmorianum, the Maxillary
Sinus (q. v.).                      I.  H.
   ANUS.  This term is  applied to the
outlet or passage by which the faces are
discharged from  the body.  Properly speak-
ing, it is not  a simple opening,  but rather
a short  canal formed by the termination
of the internal integument of the  rectum
and a portion  of the skin, inverted and ren-
dered continuous with the intestinal mu-
cous membrane.  It is provided, moreover,
with certain  muscles especially intended
to control  it, and  it gives  attachment to
several others which exercise more or less
influence over its motions.
   Art. I.  Anatomy of the An vs.  The
anus is situated on the median  line of the
body, about an inch before  and  below the
point of the os coccygs. When examined 
                                AiN JS.

externally, and at rest, it presents the ap-
pearance of an oval or linear slit, its long
diameter being in the antero-posterior di-
rection, and its sides in contact; but when
distended by the passage of feeces or other
solid bodies, it becomes circular.  The di-
rection of the canal  of the anus is from
without; inward, upward and forward: its
extent is generally about an inch and a
half, from the surface of the body toward
the spot where the last curve of the rec-
tum  loses  its close  attachment  to the
prostate gland.  This canal  is formed by
the  action of two  muscles called the
sphinctores ani.  Were it not for the pre-
sence of these muscles, the rectum would
retain a calibre approaching to its mean
diameter, until united to the external in-
teguments. The aspect of the anus ren-
ders  this fact  sufficiently obvious, for the
sphinctores ani gather the mucous mem-
brane into longitudinal folds, or columns,
and  the neighbouring skin, into  radiated
plaits, which extend to a considerable dis-
tance into the intestine and on to the sur-
face. This superabundance of integument,
about, and within the anus, permits all ne-
cessary distension to take place  without
any  great danger of laceration,  but this
accident  does occasionally happen not-
withstanding the care with which nature
has guarded the part.
   a.  Of the  Integuments of the Anus.
The junction  of the skin with the mucous
membrane in the anus does not take place
suddenly.   Even before we  arrive at the
orifice, the colour has become changed to
a yellow or brownish hue, much more re-
markable in the adult  than in the child;
and  it is bathed by a peculiar unctuous
discharge from numerous follicles.  After
puberty, especially in the male, it becomes
surrounded with  numerous  long  hairs,
which are not without their share of im-
portance both in health and disease. After
entering the anus, the skin changes its
character, gradually and  insensibly, so
that it has been thought impossible to say
where the  cutis terminates,  and where
the mucous membrane begins. According
to M. Cruveilhier,  the  cuticle  extends
to some distance above the anus,  and ter-
minates  in an irregular festoon; an ar-
rangement which we sometimes see  most
evidently,  at the oesophageal end of the
stomach. (Diet. Pratique. Art. Anus.)
  The radiated plaits, just mentioned, pro-
duce considerable irregularities of surface,
which become more and more conspicu-
ous as they approach the verge  of the
anus; and within the  canal, these irregu-
larities are  often rendered still more re-
(Anat.)                              79

markable, by several elevations  and de-
pressions, to be described hereafter,  and
also by the enlargement of the neighbour-
ing veins, the deposition  of effused mat-
ters beneath the skin, or other slight mor-
bid changes; some traces of which are vi-
sible  perhaps in the majority of adults.
This  unevenness of surface gives rise to
inconvenience,  or  disease, when  strict
cleanliness  is  neglected,  by  permitting
the local accumulation of  faecal matter, or
altered  secretions;  and in some  cases it
furnishes a lodgment for entozoary animals.
   The  mucous  membrane of the rectum
is very  redundant in every direction until
it approaches the anus.  It is sometimes
thrown into irregular wrinkles, principally
ranged  transversely, and  sometimes  into
strongly marked ridges running  round a
considerable portion of the circumference,
simulating the valvulse conniventes of the
small intestine.  Occasionally, the rectum
is encroached upon by transverse parti-
tions, reaching, in  extreme cases, across
one third of its calibre, or even more, and
dividing it into a series of very large cells
resembling those of the colon, except in
the fact that none of the coats of the rec-
tum except  the tegumentary membrane
enter into the formation of the partitions.
(Vide Rectum.)
   But when  the intestine displays itself,
to form its terminal pouch, just above the
commencement of the anal canal, the re-
dundance of the mucous coat becomes less
obvious in  the longitudinal,  and  much
more so in the circular direction.  The
longitudinal duplicatures are not so irre-
gular or numerous as the radiated folds of
the external  integuments.   They are call-
ed the  columns of the rectum (see fig. 2.
A, A, &c. p. 83.), and their number  and
position seem to be  in great measure de-
termined  by a  peculiar arrangement of
the longitudinal muscular fibres of the in-
testine, which will be described hereafter.
There  are from four to ten,  or more, of
these columns,  of unequal dimensions;
and when the  number  is considerable,
some of them are generally rudimentary.
(See fig. 2. B, B. p. 83.).  They enter the
canal of the anus, diminish in size as they
proceed downwards, and terminate rather
suddenly very near the level of the lower
edge of the internal sphincter, at  the spot
where it produces its  strongest contrac-
tion. (See fig. 1. E.  p. 81.). They throw
the surface of the superior part of the anal
canal into  a series of longitudinal ridges
and sulci, which have certain physiological
and pathological relations, to  be  noticed
hereafter. Some other important remarks 
80
ANUS. (Anat.)
on the distribution of the integuments of
the anus will be better understood if treat-
ed in connexion with the muscular fibres
that control the actions of the part
   The skin around the anus is separated
from the muscular parts beneath,  by an
■abundance of fatty cellular tissue;  but at
•and  within the verge, it  is much more
closely adherent The mucous membrane
immediately above the anus, adheres very
slightly to the muscular coat of the  rec-
tum, their connexion being effected by
means of very lax  cellular  tissue.   In
strong efforts to discharge  the feeces, this
membrane is frequently rolled out  before
the escaping mass, so as to form a ring or
scroll around the outlet which disappears
when the efforts have ceased.  In persons
of costive habit the frequent repetition of
this  accident, increases the liability to its
recurrence, and enlarges the size  of the
scroll, until it becomes obvious at  every
stool, and may materially embarrass the
discharge.
   b.  Of the Muscles of the Anus.  There
are  two  muscles proper to the anus,  one
common  to this part  and other pelvic vis-
cera, and several others which  produce
more or less impression upon the position
of the outlet; they will be more fully de-
scribed under the head of Perineum  (q. v.).
It is proper, however,  to make a few re-
marks upon the three first of these mus-
cles, in the present article, and also to de-
scribe the action of the longitudinal fibres
of the rectum upon the mucous membrane.
   The  Internal Sphincter of the anus
(fig. 1 and 2. C.)  is  composed  of a band
of circular or arched  fibres, forming  part
of the corresponding plane of the muscu-
lar coat of the rectum.   It is situated im-
mediately below the terminal  pouch of
that viscus, after it leaves the level of the
prostate gland, and it surrounds the upper
part of the canal  of the anus.   It  varies
from half an  inch to an inch and  a half
in breadth; it is thin at its superior edge
where it is amalgamated with the muscu-
lar plane just mentioned (Jig. 1. L.), but
becomes  more distinct as it descends, un-
til it reaches  its lower edge, where it is
strong and well marked.   This  muscle
forms a small ring,  slightly oval,  which
does not close the extremity of the rectum
firmly and accurately, except perhaps near
its lower edge.  Internally it is separated
from the  mucous coat by the hemorrhoidal
plexus of veins, some branches of  which
traverse  the  substance of the muscle.
   The External Sphincter (fig. 1 and 2.
F.) is much larger and stronger than  the
la6t  named muscle.   It  occupies nearly
one half the interval between the tubero-
sities of the ischia, and has considerable
thickness.   In general form, it resembles
an oval ring, somewhat acuminated at the
extremities of its  long diameter,  which
lies in the  antero-posterior direction.  The
outlet of the  anus is found in the centre
of this muscle, of which the fibres are
parted  into two distinct columns behind,
and are again reunited in front, in such a
manner as to produce the elongated shape
of the outlet.  The sphincter externus ori-
ginates in a point, from the cellule-fibrous
matter about the extremity of the os coccy-
gis.   In front of this bone its fibres de-
cussate each other at the median line, as
far forward as the posterior extremity of
the outlet of the anus. From these sources,
the fibres diverge, in two columns, pursu-
ing a cycloidal  curve around  the outlet,
and reuniting on the median line in front
of the anus, from its anterior extremity, to
the spot where the various perineal mus-
cles are united to each other.   The  outer
fibres have there an acuminated insertion,
extending  as  far forward as the bulb of
the urethra.  In the female, this muscle is
continuous  with  the  sphincter vaginte.
For further details as to the external at-
tachments of this muscle, see the article
Perineum.
   The  sphincter  externus is  separated
from  the skin of the perineum by a thick
layer of fatty cellular  tissue, which also
penetrates occasionally between its fibres;
but within the verge,  this layer becomes
quite thin, and much less adipose.   The
lower surface of the  muscle is broad and
flat.   Its  superiw fibres rise  above the
inferior  edge of  the internal sphincter,
which they embrace, and with which they
are sometimes intermingled  to a  slight
degree.  The inferior fibres are consider-
ably below the edge just mentioned, and
the point of greatest contraction is near
the lower surface (fig. 1. G.).
  Between the  two spots where the in-
ternal and external  sphincters  produce
their  strongest contractions, there  is an
enlargement of the canal of the anus, very
slight, it is true,  but highly important in
its relations to the history of anal disease.
  The termination of the plane of arched
muscular fibres forming one layer of the
muscular coat of the rectum, and consti-
tuting'that better developed band known
as the  internal sphincter, forms a small
funnel-like  cavity, with  its superior or
broad opening looking upward, toward the
prostate gland and  the bas-fond of the blad-
der, and its lower part, or neck, nearly or
quite  closed by the lower edge  of the
sphincter.  This funnel forms one half or
more  of the canal of the anus, and may 
ANUS.  (Anat.)                               81
vary in length from half an inch to  an
inch and a half between  its extreme li-
mits.   The columns of the rectum form
from four to ten, or more, strongly marked
ridges, and a  corresponding number  of
grooves,  placed longitudinally along  its
internal surface,  becoming narrower as
they descend, and  terminating abruptly at
its lowest part.
   The walls of this funnel are received
into another  shorter space, of a  shape
somewhat similar, formed by the divarica-
tion of the fibres of the external sphincter;
 which,—being much more considerable
 above, and gradually diminishing below,
 until, at the outlet, it nearly disappears,—
creates another muscular funnel, covering
 the first at its neck and for some distance
above, but extending downward about half
an inch lower, to the point of greatest con-
traction of the external sphincter.  The
tegumentary membranes  are  continued
from the orifice of the inner, to that of the
outer funnel; and between these points,
they are allowed some room for the slight
enlargement before mentioned, which may
be regarded as the  middle region of the
anal canal. These are minute details, but
their importance  will be  more  fully de-
veloped hereafter.
   It is now necessary to speak of the ter-
minal  arrangement  of the longitudinal
 muscular fibres of the rectum, and of their
action on the anus; and here we are happy
 to bear testimony to  the importance of the
additions made to our  knowledge of this
subject by the  present  Professor of Ana-
tomy in the  University of Pennsylvania,
whose kindness in demonstrating his  se-
ries of preparations of the rectum enables
us to present a more full statement of this
arrangement than has  yet been given to
the public.
   The longitudinal fibres of the  rectum
have been heretofore described as partly
terminating in the  superior margin and
the outer  face  of the  internal sphincter
(fig. 1. i.), and partly continued over that
face to be lost in  the external, where it
overlaps the internal sphincter (fig. 1. k.).
Some of these  fibres do indeed terminate
as described, particularly at the latter spot
but Dr. Horner has  succeeded in tracing
others of these  fibres much farther.  Very
many of them  begin to lose a portion of
their  muscular appearance  as  they ap-
proach the lower edge of the  internal
sphincter,  assuming  somewhat the aspect
of tendons;  they are here gathered into
numerous  small fasciculi,  the  fibres  of
each fasciculus  seeming to adhere to each
other, until they double beneath the edge
of the internal sphincter, which they ap-
pear to employ as a trochlea to revert the
direction  of their motion (fig. 1. 1.), and
are reflected upward on the mucous mem-
brane. At this point (i. e. where they are^
reflected upward) they are collected into
groups, one corresponding with  the  base
of each column of  the rectum;  to which
it  adheres  pretty closely in its passage.,
Each group then pursues its  course up-
ward in  the dilplicature of the  column;
but it speedily resumes  its muscular as-
pect, the fibres being rapidly displayed as
they advance, until they are finally insert-
ed into the  mucous  membrane, sometimes
as high as an inch and a half or two inches
above the inferior edge  of the sphincter
internus  (fig. 1. m.).   It is obvious  that
this arrangement gives  these fibres the
power to draw down or even to revert the
base  of the columns, and a portion of the
mucous coat of the rectum, thus explain-
ing more fully the real nature of prolap-
sus ani; especially that species of it which
occurs most frequently in childhood.  A
similar structure is obvious in the horse
and other animals.
 A vertical section of the Parietes of the Anns, passing through the
middle line of one of the columns of the Rectum, and the neighbour.
ing parts.
viaea.
  D, D. The plane of arched fibres of the muscular coat, similarly
divided.
  E. The point of greatest contraction of the internal sphincter.
  F. The External Sphincter.
  G. Tbe point of greatest contraction, of the same muscle.
  H. The plane of longitudinal fibres of the muscular coat, longi-
tudinally divided,  i. Some of these fibres terminating in the internal
sphincter, k. Others, terminating in the external sphincter.  1. The
remaining longitudinal fibres, collected into a semi-tendinous fascicu-
lus, passing over the lower margin of the internal sphincter, to be re-
verted upward within the duplicative of the column, m. These re-
verted fibres again becoming muscular, and terminating in the  mu<
cous coat.
  L. The mucous coat.
  n. A bristle in one of the sacs. 
82
ANUS.  (Anat.)
  The Levatores Ani are two muscles ori-
ginating from the internal surface of the
pelvis, and inserted  into each  other, or
into other soft parts along the median line
of the body, in such a manner as to sup-
port and press upon the contents of that
cavity and the abdomen from beneath, as
the  diaphragm does from above.  These
associated muscles close the pelvis below,
forming a kind of basin of fibres with the
concavity directed upward.   The  fibres
originate  from the bones  of the pelvis,
either directly, or through the interven-
tion of the perineal fasciae.  They are di-
rected, from the circumference of the pel-
vis,  downwards and  inwards, until they
reach the median line,  or the outlets of
the organs which are situated there. The
anterior  fibres are attached around the
membranous portion  of the urethra, and
the prostate gland ; the lateral fibres are
commingled with those of the outer mar-
gin of the external sphincter, and the pos-
terior ones decussate  their fellows of the
opposite  side, between the anus and the
os coccygis.  For a more detailed account
of the origin  of these muscles, see Peri-
neum.  Our present business is only con-
nected with their action on the anus.
  The levatores  ani  are the proper anta-
gonists of the external sphincter.  Their
lateral fibres act  most rapidly and exten-
sively by drawing apart the two columns
of that muscle, thus converting the ellip-
tical form of the anal  orifice into a circle;
but  their  action does not cease here, for
their anterior  fibres  are inclined  back-
wards, and their posterior ones, forward,
so that when  called strongly into  play,
they all contribute to  the enlargement of
the anal orifice.
  When at rest the anus hangs suspend-
ed on the levatores ani, and such is the
obliquity of the  fibres  of these muscles,
that even when they  are in action, if the
rectum and abdominal muscles remain
passive, they merely raise  the  orifice  a
little, without producing any very material
impression upon  the  external sphincter.
It is only when the  rectum  and its con-
tents are forced downward by the  contrac-
tion of the  colon, or  the abdominal  mus-
cles, that their power  expends  itself in
producing dilatation.  The other perineal
muscles are only indirectly interested in
the movements of the anus.
  c.  Hemispherical  Eminences  of the
Anus.  That part of the canal of the anus
which we have styled the middle region,
presents  several  slight, somewhat hemi-
spherical or semi-ellipsoid swellings, cor-
responding, in number and position,  with
the bases of the  columns of the rectum.
They are probably produced by some pe-
culiarity in the arrangement of the vessels
of the part, and  are  not  always very ob-
vious after death.  These appear to be the
primary seats of those  slight  tumours
which are so generally observed at the
sides of the anus during the expulsive ef-
forts of the rectum, returning within the
canal upon the cessation of those efforts.
When these tumours are enlarged by dis-
ease, their return^ may be  prevented by
the contraction of the external sphincter,
and  the lining  membrane  of the canal
rests permanently everted to a greater or
less extent. This is one of the most com-
mon forms of what  are termed, not per-
haps with rigorous propriety, external he-
morrhoids (q.  v.).
  The  swellings just mentioned are so
closely approximated, when the parts are
at rest  that they are in contact with each
other about the middle of this part of the
canal.  The sulci formed by their gradual
recession from each other  above,  corre-
s]iond in number and position with those
which separate the  columns  of the rec-
tum, and they  may be regarded as the final
termination of those  grooves.  They are
the seat of another peculiar and highly
important  arrangement,  which  we will
now describe with some  care, as  we be-
lieve that no accurate description of it has
ever been presented to the public through
the medium of the press.
  d. Sacculi  of the  Anus.  The venera-
ble Emeritus Professor of Anatomy in the
University of  Pennsylvania, had been in
the habit of noticing in his former annual
course of surgical lectures, a peculiar con-
dition of the  anus, in which  there  exist
certain well-defined pouches or sacs with-
in the canal,  which,  by occasionally ar-
resting small portions of faces, or minute
foreign  bodies, give rise  to great incon-
venience, and demand the performance
of a peculiar  operation for the relief of
the patient   (See Art. III. § 12.)  Dr.
Horner,  in prosecuting  some  examina-
tions, post-mortem, with the view of eluci-
dating this subject was surprised to find
a series of semilunar valvules, within the
canal,  such as have  been  hinted at  by
certain anatomists, as an occasional occur-
rence, but the  existence of which has been
repeatedly denied by others.  His atten-
tion being once fairly called to this struc-
ture,  Dr. Horner discovered these val-
vules in every body which  he examined
for the purpose, and  therefore draws the
legitimate  conclusion that they are nor-
mal and constant.  The following descrip- 
ANUS.  (Anat.)
83
tion is drawn from the appearances pre-  submit to examination, and the accompa-
sented by four different preparations, taken  nying figure has been  executed from one
promiscuously from a considerable number  of them.
which the Professor did us the favour to
Fig. 2.
 A vertical section of the anterior parietes of the anus, with the whole canal displayed so as to show the
relations of the sacculi of the middle region, and their relations to the surrounding parts, their orifices
being marked by bristles.
 A, A. Columns of the Rectum. B, B. Rudiments of Columns. C Internal Sphincter. F. External
Sphincter. I. Rudimentary or imperfect Sacculi. K, K. Radiated folds of the skin, terminating on the
surface of the nates.
 n. A bristle in one of the sacs.
   Immediately  below the margin of the
internal sphincter we find a series of mem-
branous pockets or sacculi, corresponding
in number with the grooves between the
columns of  the rectum,  one of which
grooves  is directed  towards,  and termi-
nates in, each of the culs-de-sac.  On the
outer side,  the  sacculi  are  lined  by the
mucous  membrane  of the grooves, pro-
longed  into  the intervals of the  hemi-
spherical eminences already noticed, but
which are not  sufficiently distinct  after
death, to be well represented in a drawing
from  nature.  Internally,  or on the side
next  the canal, the sacculi are completed
by portions of loose membrane, which are
processes from  the  reverted integuments
lining the canal  below.  Each of these
loose  portions is attached at either end to
the base of one of the columns of the rec-
tum, and its free margin hangs in a curve
between these points, thus forming a purse
with  the mouth presenting upwards, and
resembling, in some degree, one of those
formed between the valves of the aorta
and the parietes of that vessel.   Unlike
the sacculi said to be  sometimes  formed
by the  intersection of the transverse and
longitudinal folds of the  rectum near the
upper part of the anal canal, these pock-
ets may be compressed, but cannot be ob-
literated  by  the distension of the anus.
Their number, form, and position must ne-
cessarily vary, with those of the columns
and swellings, which give  them  attach-
ment; and, like the columns, some of them
are frequently rudimentary.  The upper
margins of these  pockets, taken  collec-
tively, appear to form the  festoon mention-
ed by Cruveilhier as the termination of
the cuticle.
  The  importance of the  relations be-
tween these  pockets and the phenomena
of fissure, stricture, &c, are subjects for 
84                              ANUS.  (Anat.)
future examination.   As to their physio-
logical uses, this is not the proper place to
discuss all the ideas which they suggest;
suffice it to say, that numerous mucous
follicles  appear  to  discharge themselves
into their  cavities, and that the passage
of faeces must compress them and expel
their contents, thus  aiding in the lubrica-
tion of that part of  the anal canal which
is invested with  cuticle, and therefore less
capable  of protecting itself, particularly
at  the moment when this lubrication  is
most necessary.  The occasional existence
of such sacs, or, as they have been termed,
lacunae,  or valves in the anus, has been
noticed by several writers: M. Ribes, one
of the most laborious investigators of the
pathology of the rectum, refers to Glisson,
Ruysch,  and Morgagni,  as among the
number.   This  gentleman,  in  an essay
written some years ago, stated that he had
been totally unable to detect them  in the
course of  his dissections, though pursued
for twenty-five  years.  He mentions, in-
deed, three or four depressions apparently
lined with external  integument, and  per-
fectly smooth, placed in the anus, four or
five  lines  above the margin, resembling
the dilatations of the aorta and pulmonary
arteries  after the removal of the sigmoid
valves, but he could not detect any open-
ing or loose membrane about them.   It
seems probable, then, that he was deceiv-
ed by the collapse  or obliteration  of the
cavities, which prevented  his  observing
the free margins of the valves, as they
have been improperly called ; this  is the
more probable,  as  his attention was par-
ticularly directed to the condition  of the
parts when in a diseased  state, from the
existence  of fistula in ano. (Recherches
sur la situation de Vorifice interne de la
fistule a Vanus.  Rev. Medicale,  1820.)
In a more recent essay on the same  sub-
 ject  M. Ribes describes  these pockets
with considerable  accuracy, stating that
he has found in one subject, four,  and in
others,  three depressions,  protected  by
their loose, semilunar,  valve-like  cover-
 ing,  and  that  in the  intervals between
 these, others less developed were noticed.
 (Memoires de la Societe <EEmulation. IX.
 107.)  Nowhere, however, are the pre-
 cise position and connexions of these parts
 described  with  accuracy, though the  au-
 thor just quoted remarks that they are ex-
 ternally in contact  with the hemorrhoidal
 plexus,  and that  the slightest wound or
 ulcer on their inner surface must endan-
 ger the occurrence of fistula.
    Many authors have described the  ap-
 pearance of culs-de-sac somewhat similar
to these pouches, formed by transverse du-
plicatures of the mucous tissue just above
the anus or in the upper portion of its ca-
nal, passing from one column of the  rec-
tum to  another.  No doubt they may oc-
casionally exist  but M. Ribes  declares
that he  has never  been able to  detect
them. The numerous partial partitions of
the rectum,  sometimes formed by the mu-
cous membrane still higher up in the ca-
nal,  are  altogether beyond  the range of
the  present article, and cannot be  con-
founded with these  more constant and re-
gular valvules. (See Rectum.)
  The third and least considerable portion
of the anal  canal is formed by the inver-
sion of  the external  integuments.  Its
length is determined by the  thickness of
the  skin and  subcutaneous fatty cellular
tissue, and in emaciated individuals it dis-
appears  almost  entirely, or  is converted
into a simple areola.  In health it forms a
very wide and short inverted funnel,  with
the surface thrown  into strong and numer-
ous  radiated ridges by the action of the
sphincter externus.  It is generally much
more depressed in the male than in the fe-
male, and the sulcus  or groove between
the  thighs,  in which the outlet is placed,
is also much deeper in the former than in
the  latter.  In the female,  indeed,  it  is
placed almost on a level with the tubero-
sities of the ischia.  The upper  part, or
neck, of this  funnel, is elliptical,  and  is
surrounded by those fibres of the external
sphincter which are placed below its point
of greatest contraction.
  e. Vessels of the Anus.   The arteries
of the anus are  small, but  in operations
upon this part they sometimes require the
ligature. They are principally the branches
of the external pudic, styled the inferior
hemorrhoidal arteries, and a  few ramifica-
tions of the ischiatic artery.
  The  veins  of the anus are much more
important  They are derived from the in-
ferior  mesenteric,   pudic, ischiatic,  and
middle hemorrhoidal veins. The first men-
tioned vessel, being a  part  of the portal
division of the circulation, is deprived of
valves; and the same character is given to
the hemorrhoidal plexus, formed by the va-
rious branches just enumerated. This plex-
us  constitutes a free connexion between
the portal, and the general venous system,
and is therefore highly important in a me-
dical, as well as surgical point of view.  It
surrounds the mucous coat of the rectum
above the verge of the sphincter internus.
When  they  are  rendered  varicose,  or
much distended, the branches of this  plex-
us  form projections in  the  canal, which 
ANUS. (Physiol.)
85
are of a blueish tint and might be mis-
taken  for the veins  themselves,  so thin
and transparent is the mucous coat which
covers them.  They  are embraced exter-
nally by the  sphincter internus; but M.
Ribes  remarks  that  "tolerably,  large
branches of the plexus are detached, pass
through the muscle to its back, and imme-
diately descend on its external face to its
lowest edge, where they communicate
anew, as it were, with the lower border
of the  hemorrhoidal  plexus."  (Loc. Cit.)
This arrangement he observes, when per-
sons have been  subject to violent attacks
of piles, occasions the sphincter to resem-
ble a portion of erectile tissue, in conse-
quence of  the  number of large vessels
which  penetrate  and embrace it  (Vide
Hemorrhoids.)
   The lymphatics of the lower and per-
haps most of those of the middle portions
of the anal canal, traverse the glands of
the  groin,  which  are not  unfrequently
swelled in certain cases of irritation about
those parts.  The lymphatics of the upper
or mucous  portion of the  canal, traverse
the glands of the pelvis.
   f.  Of the Nerves  of the Anus.   The
sources and distribution of the nerves of
the anus, have not yet received that rigor-
ous examination which the importance of
the  functions  over  which they preside
would warrant and render desirable. They
are principally derived from the hypogas-
tric plexus, and the last sacral pair  of ce-
rebro-spinal nerves.  They therefore com-
municate  partly  voluntary motion and
feeling, and partly involuntary motion and
internal sensation; but the precise degree
in which each portion of the canal enjoys
these  several powers,  has not yet been
satisfactorily demonstrated by dissection
or experiment
   Bibliography.—Ribes, (M.)   Recherches sur
la situation de  Vorifice  interne de la Fistule  a
I'Anus.  Revue Medicale, 1820.  The same, en-
larged, and with further anatomical researches.
Rev. Medicale.  IX. 107.  Paris, 1826.
   Horner, (VV. E.)  Treatise on  Special and
General Anatomy.  8vo. vol. 2d.  Philada. 1826.
   Jourdan and Breschet.  Note to their Trans-
lation of Meckel's Anatomy.  Doane's English
version. III. 273.
   Cruveilhier, (M.) Art. Anus,  in  Diet, de
Med. Pratique.  Paris, 1830.

   Art. II.   Physiology of the Anus.
There are but few  remarks to be  made
under this head, except those which relate
to the motions  of the part; for in  other
respects, the subject falls naturally under
the heads of the several tissues interested
in the formation of the  canal.
   It has been too generally customary for
   vol. n.           8
writers on the anatomy and physiology of
the anus to confuse the two sphincters to-
gether in their descriptions.  Now these
muscles are not only distinct in their posi-
tion, but in their physiological relations also,
the one properly belonging to the splanchnic
or involuntary muscular system, the other
to that of voluntary motion, though possi-
bly they may both be somewhat mixed in
character.   We shall speak first of their
situation when in repose, and then of their
several actions and their effects.
   In the healthy state,  the  tonic contrac-
tion of these muscles is not sufficient to
close the anal canal with any great force.
The internal is much more contracted
than the  external, but does not produce
very firm pressure upon the hemorrhoidal
plexus, or the mucous  membrane ; nor is
it in turn pressed upon strongly by those
fibres of the external sphincter which sur-
round its neck.   A cautious examination,
by the eye or finger, made without touch-
ing the verge of the  anus, shows us that
the two columns of the external sphincter
are  pretty  widely separated from  each
other; but nervous sensibility and irrita-
bility  are concentrated around this, as
around the other great outlets of the body;
and the effort to introduce the finger with-
in the canal, sometimes produces a pow-
erful contraction, which is  almost if not
entirely, involuntary.   This occasionally
gives rise to a difficulty in introducing the
injection  pipe, but it is remarkable  that
the  effort generally  subsides  when the
passage has been effected, like  the  spas-
modic  contractions of  the  rima glottidis
when  a  catheter has  fairly entered the
trachea.   The  internal sphincter opposes
a constant resistance to the discharge of
the faeces as they accumulate in the great
pouch  of the rectum.  It seems to contract
more and more strongly, while this accu-
mulation is going on, until the pouch itself,
aided by the voluntary efforts of the indivi-
dual, is about to determine an evacuation;
when it becomes relaxed in the same man-
ner, or is distended by the same  forces, as
the  circular sphincters of other hollow
viscera.   It does not  appear that the ex-
ternal  sphincter contributes in any consi-
derable degree to this power of steady re-
tention.   The former muscle being  fun-
nel-shaped,  its upper portion assists in re-
taining solid faeces only, and it also moulds
or compresses them when  in the act of
passing; so as  to prevent  the  too great
distension of the middle region of the anal
canal.  Upon semifluid matter it can ex-
ercise  but little influence, and when a
considerable quantity of liquid collects in 
86                             ANUS. (Physiol.)
 the rectum, even the lower margin proves
 an insufficient guard,  and powerful and
 exhausting voluntary efforts of the exter-
 nal sphincter are demanded to give a tem-
 porary and imperfect security against its
 passage.
   When the rectum is  nearly empty, the
 internal sphincter is scarcely antagonized
 by the longitudinal fibres; but when  that
 intestine is  distended,   the  form of its
 pouch,  enlarging  rapidly in  every direc-
 tion from the anus, enables them to act at
 a  considerable mechanical advantage, on
 the  orifice of the  funnel;  particularly
 when its upper part is much dilated.
   The   external  sphincter  is  intended
 chiefly to resist an  impending discharge
 when its colleague is in danger of being
 overpowered, and is antagonized by the
 levator  ani.
   The action of the levatores ani muscles
 does not appear to be very powerful. They
 act rather by supporting the sphincter ex-
 ternus at its proper level, than by actually
 dragging its columns asunder. When the
 latter is completely relaxed and thrust
 open by the descent of the anus under ab-
 dominal pressure, it is evident  that the
 oblique  fibres of the levators, if they did
 not contract, would permit the sphincter
 externus to descend also; and anatomists
 generally  appear  to have taken it for
 granted that  such is the fact.  Notwith-
 standing the resistance of the levatores,
 says Berard (Diet, de Med. Edit. 2d.), at
 each contraction of the diaphragm and ab-
 dominal muscles, the anus descends; after
 which it is again drawn up by the leva-
 tors.  We have endeavoured, by repeated
 inspections, conducted with care, to ascer-
 tain the true  character  of these motions,
 and have come to the conclusion that the
 external sphincter does  not participate in
 the descent of the anus, unless when there
occurs a severe straining.  Upon the first
 effort at expulsion,  the columns of the
sphincter are thrown widely asunder with-
out changing their  level, or sometimes
 they even seem a little raised by the fibres
of the levators, and  their outlet assumes
a circular form.   Through the space thus
allowed, the superior portion  of  the anus
descends  until  the  internal  sphincter
 reaches, or  even slightly passes the lower
 margin  of  the external, and these two
 muscles  then act  in concert to resist the
 farther dilatation of the orifice. This open-
 ing of the  external sphincter also affords
 firmer support to the pouch of the rectum,
 without embarrassing the  necessary mo-
 tions of the anus.  Now it is evident, that
 if this muscle does not  descend when di-
 lated, the fibres of the levators are short-
 er, or more contracted, in that condition
 of the parts, than when the sphincter is
 in action.   When the efforts at expulsion
 cease, it is therefore obvious that the anus
 ascends, not by the contraction of the le-
 vatores ani, but by the natural elasticity
 of the parts, and by the tonic contraction
 of the external sphincter, then no longer
 counteracted by that of the levatores. The
 shape of the double funnel  formed by the
 two sphincters, as described in  the last ar-
 ticle, explains the mechanism of this ope-
 ration in a most satisfactory manner.
  The nerves which supply the muscular
 coat of the  rectum  are known to be de-
 rived from the ganglionic apparatus; those
 of the sphincters are said to spring from
 the spinal marrow;  but the character of
 the sphincter internus, its connexion with
 the common intestinal plane  of  arched
 fibres, its analogy to the pylorus and the
 cervical  fibres of the bladder and uterus,
 may reasonably lead us to doubt whether
 it  can act as a voluntary muscle in  all
 persons, and under ordinary circumstances.
 The close  association  existing between
 the several great divisions of the nervous
 system, renders all its parts mutually de-
 pendent  There is probably no muscle in
 the body absolutely and at all times inde-
 pendent  of  the will, nor is there any that
 may not be  called upon to  aid in  certain
 involuntary  actions necessary to the main-
 tenance of life.  In the act  of respiration,
 for  instance, when  regularly perfonned,
 the muscles attached to the clavicle and
 scapula remain  passive;  but  in  certain
 cases of thoracic  effusion, and of cerebral
 injury, there  is hardly a muscle  of the
 trunk, or neck, that does  not display the
 power  of regular involuntary  action,  in
aid of the  process.   No  doubt the two
sphincters both enjoy certain similar pow-
ers, and it may  be that each  receives a
supply of nervous filaments from the cere-
brospinal, and also from the  ganglionic
apparatus; but both analogy and attentive
observation lead us to  consider the inter-
 nal muscle  as more immediately under
the control of the splanchnic; and  the ex-
ternal, under that of the  cerebro-spinal
centres.  M. Berard entertains some pe-
 culiar views on  this subject  which we
 will give in his own words.
  " In our opinion, the muscular apparatus
 which surrounds the inferior extremity of
 the rectum, may be presented in three
 different conditions,  each demanding the
 intervention of the nervous system:° 1. a
 state of contraction regulated by the will,
 to prevent an evacuation when imminently 
ANUS. (Physiol.)
87
 threatened; 2. a state of permanent con-
 traction or constriction, which retains the
 faecal matters in the intestine; a contrac-
 tion with which the will has no connexion,
 and which is nevertheless immediately de-
 pendent on the  cerebrospinal nervous
 system ; 3. a state of relaxation dependent
 on the will, and therefore equally  influ-
 enced by the nervous  centres." (Op. Cit.
 p. 277.)
   With regard to the first of these states,
 I have endeavoured in vain to detect any
 thing like voluntary contraction in the in-
 ternal sphincter, and cannot regard it as
 immediately under the control of the will,
 except perhaps in cases which form excep-
 tions to the general rule.  It appears to be
 the external sphincter alone, that resists
 an impending  evacuation in the manner
 described.   With regard  to the second
 state described, it is difficult to draw any
 distinction between this state of  constric-
 tion, and the tonic  power of contraction
 enjoyed alike by all the  muscular  fibres
 of the  body; a power  evidently more or
 less influenced by the will, in  the volun-
 tary, but nearly or totally independent of
 it,  in the visceral muscles.  This tone  is
 diminished by  any causes which produce
 enervation of the part, or which tend to
 concentrate  nervous   energy  in   other
 places. Among these causes we may enu-
 merate, that which produces the alternate
 action and relaxation of the arched  intes-
 tinal fibres so essential to their peristaltic
 movement  and  which may be  perhaps
 continued to the internal sphincter; and
 also that mental determination by which
 a voluntary muscle is  relaxed,  when its
 antagonist is called into action, as  is the
 external sphincter, when the levatores ani
 produce a dilatation of its outlet.  Accord-
 ing to our view of these actions, therefore,
 there is no peculiar nervous influence ex-
 erted upon the  sphinctores ani, but they
 are  simply  governed  by  the  same laws
 which regulate  the other muscles of the
 corresponding classes.   The necessity of
 a special nervous influence to regulate the
 relaxations of the anus, has been urged,
 indeed, by several physiologists; and the
 learned Piedmontese  Professor,  M. Bel-
 lingeri, has endeavoured to establish the
 position by experiment, in  the  course of
 his researches  upon  the  spinal  marrow,
 nervous antagonism, &c.  He asserts that
 the contractions of the sphincter ani are
 regulated by nervous fibres from  the pos-
 terior columns of the spinal marrow, while
 its relaxations are under the command of
others derived from the anterior columns.
The confusion  already complained of, re-
sulting from the want of due attention to
the distinct powers of the two sphincters,
is obvious throughout these remarks of M.
Bellingeri,  and many  important objec-
tions against the result of the experi-
ments might be founded upon the reports
of  clinical  practice,  but  the argument
would lead us into a field of discussion too
wide for the present article.  Suffice it to
say that  the  results,  as  stated by the au-
thor, are by no means conclusive, upon the
point in question; and the subject will be
hereafter considered more  at length in
some of those articles which require  an
examination  of the rival discoveries  of
Bellingeri,  Magendie, Charles Bell,
&c.  (See Nerves, Innervation, &c.)
  Those longitudinal fibres of the rectum
which adhere to the bases of the columns
of that viscus, and are then reverted, to be
inserted  into the mucous membrane, ap-
pear  to contract  with some force during
the  effort to expel the faeces.   They evi-
dently tend to draw the membrane down-
ward, so as to form a fold at the extreme
edge of the internal sphincter, which may
frequently pave the way for a prolapsus
of the kind so often observed in children.
They also tighten the corners of the semi-
lunar flaps of integument which form the
little sacs  of  the middle division of the
anal canal, and assist in compressing and
expelling the contents of these sacs, at the
moment when the feeces  are passing, and
in preventing them from arresting  por-
tions of  foreign matter,  to the injury of
surrounding parts.
  Having  thus described the actions of
the  various muscular parts immediately
connected with the anus, it only remains
to notice the  changes effected in this ca-
nal by the more remote  influence  of the
diaphragm and abdominal muscles.
  At the commencement of the efforts at
expulsion, the'contents of the colon, and
the  intestines themselves  are  pressed
downwards toward  the pelvis.  Yielding
before this pressure, the pouch of the rec-
tum is distended, and the  upper portion
of the canal of the anus begins to descend.
The external sphincter is relaxed, and the
fibres of the levatores ani contract, so as
to dilate the middle  region of the canal.
The pouch of the rectum also endeavours
to descend, but is effectually checked, ex-
cept in cases of extreme effort, by the ex-
ternal sphincter, supported by the levators.
  By the descent of the internal sphinc-
ter, the relation of the several parts is ma-
terially changed.  The integuments of the
lower portion of the  canal are evolved on
to the surrounding surface, and those of 
88                             ANUS.  (Pathol.)
the second portion take their place.  The
lower edge  of the  internal sphincter is
brought into correspondence with the line
of greatest constriction of the external, and
the two muscles then act in concert. The
longitudinal fibres of the rectum evert  the
edge of the mucous membrane in a fold that
hangs over and protects, in a measure,  the
mouths of the sacculi of the anus.  If  the
straining be severe,  the edge of the inter-
nal sphincter and the  mucous  membrane
may descend still lower, and then a con-
siderable part of the integuments of  the
middle portion of the canal may be evolved
onto the  surface; the swellings  situated
at the base of the columns of the rectum,
peculiar to this region, then appear exter-
nally, around the margin of the anus; and
owing to the pressure of the sphincters on
the lower part of the hemorrhoidal veins,
these veins become enlarged, and give the
swellings a resemblance to piles.  Under
these circumstances, the sacculi, or even
the mucous fold  overhanging them, may
come into view.
  The anus  having reached its limit of
depression, and the  internal sphincter  be-
ing still strongly contracted, the continued
pressure of the  abdominal parietes is ex-
pended in producing  distension  of  the
pouch of the rectum.  Now the fibres of
all  hollow muscles,  when distended to a
certain degree, take  on an involuntary ac-
tion and  endeavour to expel  their con-
tents, and it does not appear that the mode
of expulsion in the case of the rectum dif-
fers  materially from that observed in par-
turition or urination.  The fibres of the
internal  sphincter contract at  the same
time with those of the- pouch, but aided
by the abdominal pressure, the latter gra-
dually overcome the former. The  upper
portion  of the canal is  evolved, and at
length the anus  is converted nearly into
what its name implies—a ring.  As  the
faeces distend the orifice of the  internal
sphincter, they enlarge the  middle portion
of the anal  canal, and thus stretch and
compress  the sacculi.  The mucous con-
tents of these cavities, thus poured out at
the moment  of greatest need, must con-
tribute very much to the security of the
integuments below the margin of the mu-
cous membrane;  and the absence of this
discharge, when the faeces are fluid, and
come away without much distension, may
perhaps account for the irritations around
the anus, often following such stools.
  The sensibility  of the two lower por-
tions of the anal canal is extremely great,
but that of the superior is much less con-
siderable.   It is  probable that  the acute
 sensibility ceases contemporaneously with
 the disappearance of the cuticle, but this
 point has  not been determined with suffi-
 cient accuracy.  It is one of great impor-
 tance  in a practical  point  of view, for
 many  of the surgical operations on the
 anus,  performed by  ligature,  are exqui-
 sitely painful, and the use of the knife is
 sometimes dangerous.  In the choice be-
 tween  the two modes, therefore,  it be-
 comes highly necessary to judge  correctly
 of the degree of sensibility, as well as of
 the vascularity of the parts  interested, in
 each individual case.
   If any accuse us of too much detail in
 this and the preceding article,  we must
 plead the  importance of the subject, and
 the neglect with which it has been treated
 by most writers.  We  have introduced no-
 thing which did not appear necessary to
 display the existing state  of  our know-
 ledge of these parts, and nothing that will
 not tend to elucidate  the pathological re-
 marks contained in the next article.  For
 other details with regard to the discharge
 of faeces, see Art. Rectum.
  Bibliography—Bellingeri.   Experimenta
 in Nervorum Antagonismum.  Lecta die 22 Fe-
 bruarii, 1824. — Ibid. Experimenta Physiologica
 in Medullam Spinalem. Lecta die 13 Junii, 1824.
 From the Memorie della Reale Accademia delle
 Scienze  Di Torino. XXX.  Turin, 1826.  Ana-
 lyzed in the Journal des Progrcs des Sc. &c.  I.
 125.  Paris,  1827.
  Bellingeri.  Considirations sur le Systeme
 Nerveux, in Journal des Progres des  Sc. XIII. 78.
 Paris, 1829, from Annali Univ. di Med. Milano,
 luglio 1828.

  Art. ni.  Pathology of the Ants. In
 treating this subject we shall avoid the
 consideration  of those morbid affections
 which may be more conveniently referred
 to the articles on the pathology of the rec-
 tum and the perineum;  and  shall confine
 our observations to such diseased appear-
 ances  as  take their name from this re-
 gion, in which they are wholly or partly
 seated.   The therapeutical  and  surgical
 treatment will be given in connexion with
 the history of each  disease, in the several
 sections on 1, Neuralgia; 2, Spasm; 3,
 Atony; 4, Injuries; 5. Prolapsus; 6, In-
 flammation; 7, Blenorrhagia; 8,  Organic
 Stricture;  9, Tumours;  10, Ulcers; 11,
 Fissure; 12, Preternatural Pouches; 13,
 Abscess; and 14, Fistula. The subject of
 artificial anus being intimately connected
 with hernia and obstructions  of the intes-
 tines, will be referred to the appropriate
 articles; and much of the matter relating
to preternatural and imperforate anus, will
be most naturally  considered  under the
head of vices of conformation.  We have 
ANUS. (Neuralgia.)
89
nevertheless  devoted a  short section of
the present article to the last named error
of structure.  Hemorrhoids demand a sepa-
rate article, as they involve parts and ac-
tions so far removed from the anal region,
that their pathology could not be properly
included.
   }1. Neuralgia of the Anus.  M. Cam-
paignac (Journ. Hebd. 1st series, II. 396.)
has described, under this name, a disease
which in some of its forms is sufficiently
familiar to the profession in America.  M.
Velpeau also quotes Ullman (Encycl.
 Worterbuch der  Med.  Wissenschaft.  I.
CM.), for a  description  of the same dis-
ease.   Although we have strong  doubts
whether the primary seat of this affection
is in reality the anus, and  though further
researches may possibly prove  that  it is
not essentially a  neuralgic affection, our
avowed design of giving a view of the ex-
isting state  of medical knowledge  and
opinion, obliges us to notice it here; re-
ferring to the article Bladder,  for a more
complete account of the whole progress
of the disease.
   The causes, says Velpeau   (Diet, de
Med.  ed. 2d.  III. 2*2.),  are  unknown.
Neither redness, swelling, nor the slight-
est alteration,  are perceptible in the part.
The fundament becomes the seat of lan-
cinating pains which appear to be very
superficial, and cause the patient to dread
the least pressure on the  part   These
pains  are frequently paroxysmal in their
attack,  sometimes coming on  suddenly,
sometimes more  slowly, leaving  the pa-
tient entirely  free during the  intervals.
In other cases,  the  pains  are constant,
with occasional exacerbations.  In some
persons, the anus  appears to undergo mo-
mentary and forcible contractions, followed
by speedy relaxations; in  others, on the
contrary, it  is  seen to expand  to such an
extent  that  involuntary discharges take
place.  The  neck of the bladder soon be-
comes affected, and all the  rational signs
of urinary calculus are shortly superadded.
The symptoms are rendered more severe
by exercise, particularly if the patient be-
comes heated.
   M. Velpeau goes  on to  describe  the
train of symptoms  as  observed  in  the
urinary apparatus.  (See Bladder.)  Ac-
cording to the authorities quoted, no course
of practice has been  found  generally ap-
plicable  in this disease.  Baths, opiates,
antispasmodics, the pills  of Meglin, &c,
have  been tried, in every form, without
effect When the bladder becomes affect-
ed, the  introduction of the catheter is at-
tended with great pain and a remarkable
burning  sensation.   According to Vel-
peai, this pain sometimes ceases instanta-
neously when the  instrument has fairly
entered  the  bladder;  but  Campaignac
(Op. Cit.) remarks  that when the mu-
cous membrane of the  bladder becomes
irritated  in the progress of the disease, all
attempts at exploration are productive of
acute suffering.   He mentions, however,
a case treated by M. Cheneau, in which
the  paroxysms  were  very violent,  but
were immediately calmed  by  the cathe-
ter ; which case was finally cured by its
repeated  employment.   Velpeau  states
that those patients who have been ope-
rated upon,  under  the impression that
there were calculi in the bladder, have
generally recovered both from  the opera-
tion and  the disease.  One case only,  ter-
minated  fatally, and the subsequent  ex-
amination discovered no morbid appear-
ances either in the bladder or the anus.
A patient who complained only when sit-
ting, and who was able to pursue his usual
avocations, was  relieved by the applica-
tion of pledgets imbued with  an unguent
containing the extracts of belladonna  and
opium;  another, similarly  affected,  re-
ceived no benefit from this treatment.   In
the  case of one strong, robust patient,
baths,  general  and local bleedings,  the
pills of Meglin, and the topical  use of
belladonna and  opium,  were  employed,
but no benefit was obtained until after the
cessation of all remedial  measures; in
another,  the use of the carrot tisane, soda-
water, lime-water and milk, the pills of
Meglin  in large doses, and the pills of
cynoglosum,  finally effected a  cure. Clys-
ters and  gentle purgatives he recommends
in order to prevent the exacerbation likely
to attend on  the discharge of hardened
faeces in  eostiveness; but he confesses that
the therapeutical management of this  dis-
ease is as little  understood as its nature;
and he states that it wears  off with time.
  It appears  to us more  than probable
that several different affections have been
classed  together, by  the authorities just
noticed.  Those of the cases mentioned by
M.  Campaignac, in which the symptoms
simulate those of calculus, and which, in
their advanced  stage,  produce extensive
discharges of mucus from the urinary or-
gans, seem to resemble a disease not  un-
known in our hospitals,  the proper or  pri-
mary seat of which is the bladder:  it will
be described  at  length  under  the  appro-
priate head,  where  the question  of  the
propriety  of arranging it with neuralgic
affections will be considered. Other cases
on record were very probably the result of 
90                             ANUS.  (Spasm.)
those changes in the  structure  of the
anus, noticed by Dr. Physick, which pro-
duce false pouches in the middle and lower
region of the  anal canal; changes which
we believe had escaped detection,  until
the attention  of the profession in this
country was called to them by that emi-
nent surgeon  in his lectures.  (See } 12.)
Still there can be no reason to doubt the
occasional occurrence of genuine neural-
gia, primarily  seated in the nerves of the
anus and its  neighbourhood, similar  in
character to that which occurs in other
parts; but  we are convinced of  its ex-
treme rarity,  and feel  assured that in-
creased  attention to the condition of the
canal and the organs that surround it, will
lead surgeons  to be much more cautious
in referring cases to this head.  (See the
sections on Spasm, Fissure, Stricture, and
Preternatural Pouches.)
  Bibliography. — Ullman. Eneyclopddisches
Worlerbuch der Medicinischen Wissenschaflen.
I. 634.  Berlin, 1828.
  Campaignac.  Journal Hebdomadaire. 1st se-
ries.  I. 634. Paris, 1828.

   5 2. Spasms of the Anus.  Besides the
various  irritations  located primarily in or
about the canal of the  anus,  there are
many other causes capable  of producing
pain and spasm in that part. The associa-
tions of the  anus with  the neck of the
bladder  and the urethra  in  the male, and
with the vagina in the female,  are  so
close, both  in  consequence of their prox-
imity, and their combined action in the
performance of certain functions, that any
unusual excitement of the latter organs is
exceedingly apt  to extend itself to the
former.   Spasmodic stricture  of the ure-
thra, or  other irritations at the usual seat
of that  affection, such  as  are  very fre-
quently produced by excessive indulgence
in venery or in certain  unnatural crimes
of like character, often occasion spasmodic
contractions of the external sphincter ani
muscle,  and consequent irritation of the
lower portions of the canal.   After each
unusual  indulgence, severe burning and
sometimes lancinating pain  is felt in the
neighbourhood of the bulb of the urethra;
the patient is tormented by  a constant
desire  to  urinate, and if the absence
of stricture enables him to evacuate the
bladder  completely,  he  continues  dis-
charging the urine guttatim almost as fast
as it accumulates.  After each discharge,
a spasmodic contraction of the accelerator
urinse occasions an intolerable ardor. The
sphincter ani participates  in  the spasm,
and the  same kind of pain is experienced
in the anus. The rectum is also provoked
to expel its contents,  but  it  sometimes
succeeds with  difficulty,  in  consequence
of the constriction.  During the flow of
urine and the passage of faeces, the symp-
toms  are in a  great degree relieved, and
they are considerably mitigated by the de-
scent of the upper portion of the anus un-
der abdominal pressure, so that the patient
is induced to make frequent  ineffectual
efforts to go to stool; but the pain returns
in full force, upon the cessation of the ef-
forts.   The duration of the  symptoms is
very various; sometimes they pass off in
half an hour,  and at others they endure
for twenty-four hours or longer; while
they continue, they are often very severe.
When they have become habitual, they
do not disappear with the removal of the
usual exciting cause, but are reproduced
by the  slightest accident, such  as may
occur in riding on horseback,  over-exer-
tions, &c.;  and  sometimes an attack is de-
termined simply by  costiveness.   Parox-
ysms  that occur in the night are generally
the most painful. Cases of this character
have been  occasionally mistaken  for neu-
ralgia of the anus, the  symptoms being
very analogous. This error is more likely
to occur because of the extreme  aversion
generally displayed by the patient  to ac-
knowledge the true  cause of the  com-
plaint ; for although it is undoubtedly pro-
duced in some  instances by unavoidable
accidents,  it is  much more generally the
result of improper indulgence.
   When the same species of irritation is
extended to the neck  of the bladder, the
prostate gland,  or the vesiculse  seminales,
whether it be caused by similar habits or
by calculus,  enlarged  prostate, &c, the
train  of anal symptoms is somewhat va-
ried.  There is less burning pain in the
intervals of the efforts at stool, but there
is more soreness from severe involuntary
tenesmus;  the  external sphincter is still
spasmodically affected, but  the levatores
ani partake of the spasm, and frequently
overcome the resistance of the sphincter;
even  the muscular fibres of the rectum,
and  the internal sphincter,  may experi-
ence the same kind of irritation.   Hence
result the alternate contraction and dilata-
tion of the anus and the involuntary dis-
charges, noticed in the preceding section,
as also, the severe tenesmus, and the pro-
lapsus of the mucous  membrane, so fre-
quently  observed in  the paroxysms of
stone and  other diseases  in  or about the
bladder.
   We believe that in the great  majority
of cases, the train of symptoms just de-
scribed originates in the urinary apparatus, 
ANUS. (Spasm.)                             91
Mid that the anal affection is consecutive.
This  complaint, though sufficiently com-
mon,  does not appear  to have attracted
the attention it deserves, for its effects are
not unfrequently enumerated among the
characteristic  symptoms of diseases, of
which, perhaps, they are as frequently a
cause as a consequence.
   The treatment of the first form of this
affection  consists in the removal of the
exciting  cause, and the employment of
measures  calculated to combat spasm in
general.   Mild cases  seldom come under
the notice of the surgeon; but in  those
 which have  become  habitual, we  have
 succeeded best by the  long-continued ap-
 plication of considerable heat by means
 of bottles of hot water, and by injections
of mucilage of the pith of sassafras into
the urethra,  and, in very  severe parox-
ysms, opiate enemata.  To prevent the re-
currence of paroxysms, all that is required
is  the avoidance  of every cause of me-
chanical  irritation, violent  exercise, and
such  errors  of diet as are calculated to
render the  excretions unusually stimu-
lating.  In some cases, the  application of
local  heat increases the violence of the
symptoms, and relief is obtained from the
very opposite course.  When inflammation
supervenes upon the spasm, leeches and
cold to the neighbouring parts are strongly
indicated.  They should be addressed as
nearly as possible to the original seat of
irritation, when it can be ascertained. If,
as  sometimes happens, fever should be in-
duced, it is to be treated on general prin-
ciples.
   The treatment of the second form of
this disease does not differ essentially from
that of the first so long as it remains sim-
ple in character; but as the parts interested
are more numerous, involved to a greater
degree, and deeper seated,  constitutional
symptoms and secondary complications are
much more likely to occur.  Its causes are
often  incapable of immediate cure; the
treatment is  therefore  merely palliative,
and will  be noticed under  the heads of
the several diseases that produce it.  (See
Prostate Gland, Bladder, &c.)
   But spasms of the anus  do not always
depend upon irritation  of the urinary or-
gans.  Cases of far greater violence and
danger, though fortunately less frequently
met with, originate from irritations of va-
rious  kinds seated in the anus itself, or in
the rectum.  Mr. Calvert, who has given
a very accurate account of this disease,
describes it as appearing  at first  with
some degree of smarting pain, and a feel-
ing of resistance at the orifice  of the gut
during an evacuation.  After some time
the difficulty  of voiding  faeces becomes
much greater, the stools being rendered
small, flat, and twisted spirally as in cases
of stricture of the anus or rectum, and the
discharge intensely painful.  The dimen-
sions of the masses  of faeces are not uni-
form, being sometimes large and evacu-
ated with force and rapidity; at others, as
small as  a piece  of fine tape, and passed
slowly, with great exertion.  This varia-
tion shows that  the  spasm extends to all
the muscles of the anus, and even to those
of the rectum,  affecting  sometimes  one
part and sometimes  another, and furnish-
ing the means of distinguishing the com-
plaint from organic stricture.  According
to Mr. Calvert, the pain  comes on  soon
after the  patient has had  a  motion, con-
tinues for a short time, and does not re-
turn until the following day, or still later
if the bowels are not moved in the inter-
val ; but in persons of very irritable habits,
it may be produced by the slightest causes,
such as the escape of wind, unusual exer-
tion, passions, or any other cause of gene-
ral  or local excitement. The pain is some-
times intolerable, and  gives rise to cries
of agony.  Occasionally, it assumes a pe-
riodical character, coming on in some pa-
tients regularly,  and generally in  the
evening of each day, with  a total calm in
the intervals; and in  others, making its
attack at irregular  periods,  leaving be-
hind it a  constant uneasiness, numbness,
or  aching pain.  (Pract.  Treat, on  Dis-
eases of Rectum, &c. p. 211.).  Accord-
ing to Mayo,  the attack generally comes
on  during the night, waking the patient
with excruciating pain.   In some cases,
its  approach is gradual for several days,
and then  it as slowly declines; while in
others, it seizes the patient suddenly,  and
after lasting a certain time, as suddenly dis-
appears.  (Obs. on Diseases of the Rectum.
p. 185.)   Copeland, who  met with many
cases of constipation and other more painful
and serious consequences from contraction
of the anus, where no stricture or other mor-
bid change of structure could be discover-
ed, attributed the symptoms to an undue
development of the  sphincters, for he al-
ways found both these muscles very much
enlarged  and unusually strong in  such
cases.  Boyer, who considered spasm of
the anus  chiefly as connected with fissure
(q. v.), met with cases of difficulty so early
in life  that  he considered the disease as
congenital.  Calvert thinks it more rea-
sonable  to suppose  that   the  increased
strength  of the sphincters is owing to a
hypertrophy induced by frequent irritation 
92
ANUs. (Spasm.)
and the constant recurrence of the spasm.
The latter author remarks that the degree
of contraction is not always in proportion
to the sufferings of the patient; but when
in this complaint the sphincters are rigidly
contracted,  intense  pain is  a necessary
consequence of anything that irritates the
anus, or produces dilatation suddenly.  If,
in this state of things, the finger be passed
within the  anus, the external sphincter
muscle is found to encircle the orifice like
a thick, unyielding ring; and, higher up,
the  parietes of the gut feel unusually
firm and  solid, when pressed against  by
the point of the finger, from a similar de-
velopment and contraction of the muscular
fibres of the internal sphincter; while, in
some cases, where there  is much vascular
excitement the contraction has been found
to extend along the whole of the rectum.
(Op. cit.  p. 213.) Mayo also objects to
the  use  of opiate suppositories in these
cases,  because any attempt  to introduce
them occasions increased  contraction of
the irritated sphincters.  (Loc. cit.)  It  is
remarked by nearly all the writers, that
the persons most subject to this complaint
are females, and individuals of a nervous
temperament.
   It is much to be regretted  that so few
surgeons  have studied  the diseases of the
rectum and anus with the exercise of that
care and discrimination which their impor-
tance demands. We think it will be evident
to all who read the hasty outline of the
opinions of different authors just given,
that spasm of the anus is more frequently
a  symptom than a distinct affection, and
that writers have erred  in  enumerating
under this  head the features of various
complaints, not less  different in their ap-
propriate treatment  than in their causes
and nature. Nevertheless, we feel consider-
able diffidence in attempting to clear the
diagnosis of these affections, for, although
some of  them are met with not unfre-
quently,  and  are,  therefore, sufficiently
familiar,  there are others of rare occur-
rence  everywhere, and  almost unknown
on this side of the Atlantic,—nor are the
recorded cases and examinations presented
to us with all that detail and  precision of
language which are required to render
documentary evidence in surgery a substi-
tute for personal experience. The following
remarks, however, will perhaps prove va-
luable, by calling the attention of the pro-
fession more  particularly  to the subject
hereafter, and by explaining the confusion
and conflict of principles, so obvious in the
practical directions of authors.
   The cases  properly ranged under the
head of neuralgia of the anus and bladder,
so styled  by M. Campaignac,  as  noticed
in the preceding  section of this article,
are not  very  strongly  distinguished in
their  first rise, being  liable to be mis-
taken  for  spasm  from  irritation of the
urinary organs—the common and compa-
ratively mild complaint noticed  at the com-
mencement of the present section. They
are recognized with great facility at a later
period.  The  absence of all perceptible
disease of the rectum itself, the great ex-
tent and gravity of the symptoms affecting
the urinary apparatus while there exists
no obvious cause  for them;  the extreme
pain generally  produced by introducing
the catheter,  and  the frequent cessation
of that pain when the instrument has fairly
entered the bladder; and, more especially,
the presence of the rational symptoms of
calculus, give to this group a  peculiar cha-
racter, and the cases are more likely to be
confused with those  of  diseased prostate
gland, as  described by Home,  than with
spasm of  the anus.  (See Bladder,  Ntu-
ralgia of.)
  Another group of cases is characterized
by the ardor urinae, confined to the region
of the accelerator urinae muscle, the burn-
ing pain in the anns, and other symptoms,
originally occasioned by vicious or impru-
dent indulgence, or by injuries to the penis
from the saddle in riding, or from falls, the
improper  management of catheters, &c.
Both  the  symptoms and treatment of this
group have been considered in the com-
mencement of this section.   It is proper
to mention, however, that these cases may
no  doubt  produce consecutive changes in
the anus, and  thus bring on some of the
other  forms of spasm.   In  spasm of the
anus from urinary irritations, the constric-
tion of the external sphincter is generally
the most severe, and even this  is not com-
monly very hard; so that there  is little
difficulty  experienced in introducing the
finger.  The  strongest  diagnostic  mark
which distinguishes  spasm of this kind
from that arising from disease  originating
in the anus, is this: in the latter case, the
patient dreads the attempt at evacuation,
because of the intense agony that it occa-
sions, and the tenesmus is  only indulged
involuntarily; but, in the former disease,
straining  produces  temporary  relief, by
distending the external sphincter, and the
introduction of the finger, so far from in-
creasing,  actually diminishes the suffering.
   The sphincter  externus  is subject  to
common cramp, and  this may prove very
troublesome.  We have seen several cases,
one of which occasioned  great soreness 
ANUS. (Spasm.)
93
and considerable inflammation in the canal
for several days after the attack. The cases
mentioned by Mavo  as coming  on sud-
denly at night were probably of this cha-
racter,  but when  he draws the  general
conclusion, that "spasmodic  contraction
of the sphincter is a kind of cramp," he
certainly speaks very incautiously. There
can be little in common between cramp of
the sphincter and  the attacks coming on
gradually  and passing off in the same
manner, nor is there any stronger con-
nexion between the modus operandi of the
two plans of proceeding which he recom-
mends for the treatment of the complaint,
to wit: a mould-candle introduced as a
bougie, in some cases, and a brisk cathar-
tic in others.  Cramp of the external sphinc-
ter is a rare  occurrence, and happens ge-
nerally in persons very liable to a like
affection of the other voluntary muscles.
It is relieved by similar measures.  The
paroxysm,  in the few  cases we have seen,
was relieved  by the gradual introduction
of the finger, so as to overcome  the con-
striction, but, in two instances, it returned
repeatedly.   Both of these cases were
greatly relieved by the steady application
of heat to the part, but one of them did not
finally recover until he had been for some
time under treatment for  irritation of the
small intestines, upon which the cramp in
this and other muscles appeared to depend.
In all, the constriction was very hard,  and
the pain excessive.
   Another form of the spasm of the anus
is that  which comes  on without any ob-
vious cause, either in the urinary appara-
tus or the anus, the integuments preserving
their flexibility, and remaining unaltered,
except that they are  occasionally swelled
a little by slight  inflammation from  the
pressure of the stricture.  Cases of  this
kind are those which are so often styled
nervous.  They occur chiefly in persons
of delicate frame, sedentary habits,  and
nervous temperaments, and they appear to
result from an unusual irritability of the
anus, rendering it liable to spasm from
slight causes.  The attacks  in this form
are often intermittent appearing  at regu-
lar periods, and leaving the  patient in a
perfect  calm during the intervals. This
is the form which  has been compared by
Calvert to tic doloureux, and the causes
of which appear sometimes to be congeni-
tal.  (See  Merat. Diet,  des  Sciences
Medicales. XV. 547.)   The undue  de-
velopment of the  sphincters, noticed  by
Copeland, Boyer, and the author just
mentioned, is noticed chiefly in cases of
the group of which we are now speaking.
We are compelled to prefer the explana-
tion of this  development given by  the
latter, to that of either of the former sur-
geons, as more consistent with the ordinary
course of nature, and to regard this appear-
ance as an  actual  hypertrophy of  the
sphincters from too frequent and too violent
action.   Like other similar nervous affec-
tions, this seems to be rendered more  un-
manageable by depression of spirits and
strong  emotions of mind.  It  is distin-
guished from the neuralgia, so  called by
M.  Campaignac, by the excruciating pain
in the anus, which is sometimes so severe
as to occasion syncope, while there is Tittle
uneasiness in the urinary organs;—from
spasm consequent upon irritation in  the
urinary organs, by the intolerable agony
on going to stool, and on the introduction
of the  finger during a  paroxysm, which
sometimes produces a marked convulsion;
—from cramp of the external sphincter, by
the same signs;—and from most other cases
of spasm, by the regularity of the attacks,
or by the  absence of all strongly marked
inflammatory symptoms.   The only form
of the disease with which it is very likely
to be confounded, is that produced by As-
sure of the anus; with which it appears to
be frequently complicated, and from which
it cannot be  clearly distinguished by any
rational sign. This difficulty is of little
importance, for the surgeon can and should
determine the presence or absence of fis-
sure, in all cases of doubt  by a proper ex-
amination. (See § 11.)
  In this group of cases, the various nar-
cotic remedies  employed  in  neuralgic
diseases generally, are plainly indicated;
but the degree of benefit  likely to result
from them, cannot be foreseen from any
evidence now before us. It is probable that
most of the cases in which their employ-
ment has  proved  successful,  may  have
belonged  to  this group, and that many
cases in which they are  stated to  have
failed, may have been of a different cha-
racter,  so that the remedies were inappli-
cable to the circumstances—at all events,
the details necessary to render the question
a clear one have not been given, and it
may be  hoped that a better diagnosis will,
at some future day, remove this disease
from the list  of opprobria.   Mr. Calvert
suggests the propriety of testing the pow-
ers  of quinine and carbonate of iron, in  the
regularly intermittent cases.
  The  causes of muscular spasm, when
it occurs as  a symptom of inflammatory
affections  of  the anus, are  very various.
The complaint may be  induced by diar-
rhoea, strictures or ulcerations of the re<s 
94                              ANUS.

turn,  fissure,  rhagades,  hemorrhoids, or
other tumours,  situated in or near the ca-
nal.  This form of spasm is generally dis-
tinguished from all others by the constant
presence of more or less pain  or uneasi-
ness in the anus, the disease being liable
to remission, but very rarely to a distinct
intermission.  The treatment  of course,
must be various as the causes.  It consists
simply in the relief or cure of the inflam-
matory affection,  or  the removal of the
consequent  excrescence  which has  in-
duced the spasm.  The measures adapted
to each of the causes will be found in the
appropriate section of this article.
  Having thus attempted to classify the
several groups of cases commonly arranged
under the head of spasm  of the anus,  and,
having offered a few remarks on the treat-
ment of each  group,  it only remains to
add one or two observations on the exam-
ination of patients,  and  the  operations
sometimes  rendered necessary  in  most
forms of this disease.
   When called to a patient labouring un-
der spasm of the anus, it is the  imperative
duty of the surgeon to satisfy himself, by
careful examination, and, if necessary, by
ocular inspection, as to  the  condition of
the whole anal canal, and, as far as possi-
ble, of the neighbouring parts  of the rec-
tum.   He should inquire and ascertain if
there is any tendency to prolapsus during
the efforts at stool.  He should likewise
investigate  the condition of the urinary
apparatus, and, when necessary, the moral
habits of the patient, the condition of his
bowels, and the nature  of his  customary
diet  With these lights he will be able to
determine the true seat  and cause of the
disease, and to regulate the course of prac-
tice accordingly; but we  should be  very
cautious in pronouncing a case to be  sim-
ply neuralgic, for, in a vast majority of in-
stances, some concealed inflammation may
be detected when we take sufficient pains
to examine for it.  As a general rule, in
all forms of this complaint the bowels
should  be  kept open,  by diet,  if possible,
and if not  by gentle  laxatives or  the
mildest enemata.  No purgative contain-
ing aloes is admissible.  Perhaps the best
laxative in cases of the habitual costive-
ness  of sedentary patients, is uncombined
calomel, given in the least dose that will
produce one or at most two free discharges,
and repeated every second  or third day,
for a week  or  more, renewing the  treat-
ment from  time to time until  the habit is
conquered.   From very  extensive  trials,
we  may mention that this dose varies
from three to five grains; but generally
(Spasm.)

 the former quantity will  be found ample,
 after it has been employed two or three
 times.  All  highly stimulating  food  and
 drinks should be totally interdicted.
   As cases  of spasm of the anus some-
 times produce all the fatal consequences
 of strangulated hernia, tympanitis, or peri-
 tonitis (Richerand, Nosogr. Chir.), and,
 as many others prove at once intolerable,
 and  incurable  under medical treatment
 it  may become necessary to divide the
 sphincters, and to prevent their immediate
 reunion,  in order to relieve the constric-
 tion and  pain.   All the  writers agree in
 this recommendation; but Calvert very
 properly  cautions us against a hasty and
 unnecessary resort  to so severe an opera-
 tion, as it is not altogether unattended with
 danger;  and notwithstanding the power-
 ful  testimony of Boyer in its favour, it
 does not always effect a cure,  for it has
 failed in the hands of several eminent sur-
 geons. (See Fissure. §  11.)
   Dilatation by bougies, so very useful in
 strictures of the rectum, have  been op-
 posed  by many in those of the anus, be-
 cause  of the intense pain  attendant upon
 their introduction.  Boyer testifies that in
 every  case in which he made the attempt
 to dilate by  bougies, they proved either
 useless or injurious (Mai. Chir.  torn. X.),
 producing, in some cases, a still more rigid
 contraction after every attempt until the
 canal was nearly obliterated, so that even
 a clyster-pipe  could not be passed.  M.
 Delpech also  substantiates  this  fact
 (Precis Elementaire des Mai. Chir. torn.
 I.)  Yet there is strong authority in favour
 of the occasional usefulness of dilatation
 by tents  or bougies, even in cases compli-
 cated with fissure and other inflammatory
 affections of the canal. (See Fissure. § 11.)
 It is difficult at present to point  out the
 particular cases to which the plan of di-
 latation is applicable; but  it seems to be
 generally conceded that  even  where  it
 proves useful, the introduction of the instru-
 ment  produces  a very great exacerbation
 of pain,  which often continues for several
 hours, and then entirely subsides. When,
 therefore, the  introduction  of a tent or
 bougie is not followed by considerable re-
 lief after a reasonable time, the propriety
 of its repetition must be very questionable,
 for  we  should  then dread a  permanent
 increase of difficulty after each attempt,
 and the  occurrence of those evils noticed
 by Boyer and Delpech.

    Bibliography. — Merat.  Art. Fissure,  in
 Diet, des  Sciences Medicales.  Paris, 1816.
    Baillie, (Mathew.) Case of stricture of the
  rectum produced by a spasmodic contraction of 
ANUS.  (Atony and Injuries.)
95
the internal and external sphincters of the anus.
Trans, of Col. of Physicians of London.  V. 136.
(1815.)
  See also—the General Treatises of Calvert,
Copeland, and Mayo, on Diseases of the Rec-
tum, Boyer's  Maladies Chirurgicales, Del-
pech's Precis Elementaires de Malad. Chir., and
Bibliography of Fissure.

  5 3. Atony of the Anus.  In consequence
of frequent and  undue  dilatation  of the
anus, the two sphincters sometimes cease
to contract with  sufficient force, and the
canal becomes permanently enlarged. The
same result also happens occasionally from
paralysis  consequent upon concussions of
the spine, and the enlargement may then
continue  after the  spine has recovered
from the effects of the  injury.  Among the
most fertile causes of the worst forms of
this affection, may be ranked the  indul-
gence  in  unnatural  crimes,  fortunately
little known in this  country,  but  which
the crowded condition  of those schools of
vice, our  public prisons  and alms-houses,
are rapidly introducing amongst us.
  Slight  shades  of dilatation from atony
of the sphincters are very common  among
men of sedentary habits, more particularly
such as are esteemed good livers; though
they are seldom  made a ground of com-
plaint and have received much less atten-
tion than they deserve.   The immediate
consequences of this loss of tone  are, a
slight irritation of the teguments,  and an
increased secretion  of the mucus  of the
canal, which sometimes produce  serious
inconvenience,  although  unattended by
pain. As ulterior results, this morbid con-
dition may determine  the development of
many of the more serious diseases  of the
part under  the  action  of agents  which
would prove harmless  in a healthy condi-
tion of the anus; and these diseases may
recur after a cure has  been accomplished,
if the atony be neglected.  The complaint,
in such cases, yields almost invariably to
a regimen  and  treatment calculated  to
regulate the habitual action of the bowels,
aided by that most powerful but much
neglected  remedy in irritations  of this
part, the  local application of cold.  The
best mode of applying  this remedy is to
throw a continued stream of cold water
upon the anus; and  it  is much to be re-
gretted  that  the apparatus  for what  is
termed the douche ascendante is so  seldom
employed in this country. Cold ablutions,
however applied, are much less efficacious.
  The  worse forms of the complaint, ori-
ginating from the causes  already enume-
rated, or  from tumours, or former opera-
tions on the part,  are  attended by  perma-
nent stretching of the  teguments them-
selves,  remaining  after  the  sphincters
have in great degree recovered their tone.
Such cases yield only to  the  removal of
the cause, to the use of astringents, or, in
the most obstinate, to the excision of some
of the  redundant folds of the skin. (See
Prolapsus Ani.  { 5.)
  If the affection is the result of vicious
habits, says Velpeau, the anus is strongly
excavated,  like  a funnel;  in other  cases,
it  is  salient,  depressed, or irregular,
but  never  infundibuliform.  Involuntary
stools  and prolapsus ani are  often occa-
sioned by this kind of enlargement. When
the causes which originally produced it
are incurable, as in  some cases of tumour
and paralysis, the case is beyond the reach
of art.
  Bibliography.—Velpeau.  Dilatation de
I'anus.  Diet, de Med.  edit. 2.  III. 233.  Paris,
1833.
  Roche et Sanson. Nouvelles Elimens de Pa-
thologie. II. 527. Art. Aslhenie du Rectum.  Pa-
ris, 1828.

  5 4.  Injuries  of  the Anus.  The anus
is  subject to wounds, contusions, and la-
cerations, like other parts of the body; but
the history  and treatment of such acci-
dents require little distinct notice, being
plainly inferred from the structure  of the
canal and from well-known general prin-
ciples.  Many of these injuries will  be no-
ticed under  other  heads, and  we  will
merely remark  in  this place, that those
lacerations or incisions which  are situated
immediately in front or in rear, heal with
much  greater difficulty than those  which
have a lateral  direction,  and  are  apt to
leave crevices or linear ulcerations  in the
canal,  that are very obstinate. Dr. Phy-
sick objects to making incisions from the
anus directly toward the centre of the pe-
rineum or toward the point of the os  coccy-
gis, on account of the difficulty just men-
tioned, which he attributes to the motion
of the thighs upon each other preventing
the  continued adaptation of the  surfaces
of the wound during the cure.  He in-
forms  us that he has not observed spasms
of the  sphincters, or those grave accidents
characteristic of fissure of the anus,  as a
consequence of these crevices.  Among
the most frequent causes of injury to the
anus, we may notice carelessness  in the
introduction of injecting-syringes.   The
general construction of these  instruments
is bad, for the point  should be much larger,
rounder and shorter, to  secure the patient
against accidents from  careless operators.
The greater prevalence of diseases  of the
anus and rectum on the continent  of Eu-
rope is fairly attributed, by Mr.  Mayo, t« 
ANUS.  (Injuries and Prolapsus.)
96

the habit of constantly  taking enemata,
and for similar reasons they are less preva-
lent in this country than  in England. The
habit  may be commendable, but the care-
less  mode  of  administration  sometimes
produces  serious  evils  to the anus, the
prostate gland, or the rectum. (See Rec-
tum, Enemata.)
  The  integuments  of  the middle and
lower portion of the anal canal, are  capa-
ble of enduring great  distension when
slowly acted on,  but when suddenly en-
larged they are sometimes torn; an acci-
dent that may occur from the expulsion
of hardened faeces, or from the discharge
or introduction of foreign  bodies (Cruveil-
hier. Diet, de Med. et de Chirurg.  Prat.
Art Anus).  A longitudinal or irregular
crevice is produced, which may degenerate
into fissure or some other form of ulceration.
The superior portion of the canal is subject
to another kind of laceration, involving the
mucous membrane.   It  results from the
discharge  of  large  masses  of hardened
fieces, and is irregular, but generally trans-
verse in its direction.  It appears that this
laceration is produced by the resistance to
the progress of the  faeces, by their exces-
sive friction, or by their becoming engaged
in some of the accidental circular wrinkles
of the mucous membrane, often noticed in
this situation. The part, once torn, speedily
ulcerates.  The edges become somewhat
hardened, and the surface exquisitely sen-
sible.  The dread of pain induces the pa-
tient  to avoid all attempts at going  to
stool  as  long  as  possible,  and  thus  ag-
gravates  those very causes  that origin-
ally produced the accident, and render it
difficult of cure.   M. Mayo, who  gives
us several  very interesting cases of this
affection, describes  it under the title of
fissure, but the term fissure  (q. v.)  is ap-
plied to a class of anal ulcerations differing
materially, both  in  their seat and nature,
from the injuries of which we are speak-
ing.  (Obs.  on Injuries  and  Diseases  of
 the Rectum.)
   The symptoms and treatment  of other
 ulcerations of the anus, will be considered
 when we come to treat of inflammation of
 the anus, and its  consequences.   Their
 presence  is determined very easily,  in
 most cases, by inspection or the touch.
   A cause of injury to this part, which is by
 no means uncommon, is the introduction of
 foreign bodies from without or their lodg-
 ment after passing through  the route of
 the  intestines.   Such  causes frequently
 give rise to abscess or fistula.  It is more
 than probable that the sacculi of the anus,
 when diseased, or changed in the shape, or
limited  in their motions  by  alterations
in the surrounding parts, may contribute
much to the frequency ot the arrest of seeds,
and other small solid bodies, in the anus.
The records of surgery are rich in instances
of this kind.  These sacculi also furnish a
secure lodgment to certain entozoary ani-
mals, particularly to numbers of the Oxy-
urus vermicularis, or ascarides, as they are
incorrectly termed.  The difficulty of dis-
lodging these worms entirely is  but too
well known,  and is well accounted for by
the structure of the sacculi. We recollect
to have heard  Professor Gibson remark,
some years since, that he had employed,
with  great success,  a steel spoon  like
a  common mustard-spoon,  to scoop out
animals of this  kind.  The manoeuvre  is
worthy of record,  as no instrument could
be contrived better adapted to the purpose
of evacuating the sacculi in the most com-
plete manner, with  little force or  injury,
not only when worms are  present but
upon all analogous occasions.  Pins, nee-
dles,  fish-bones, and other sharp-pointed
bodies arrested in the anus, sometimes give
rise to great difficulty in the  extraction.
One  case  which  we  have  encountered,
suggested the use of an instrument on the
principle of the oesophageal forceps of Dr.
Bond of Philadelphia, for the removal  of
such bodies.
  Bibliography.—Payne, (Rt.) Case of a fork
thrust up the anus,and extracted from the buttock
Phil. Trans, abr. VII. 5. 1725.
  Sherman, (Mr.) Case of a fish-bone arrested
in the anus, discharged by abscess, one year after
being taken into the stomach. Phil. Trans. Mihle's
Abr. II. 367.   1723.
  Harrison, (E)  Case of an apple-core, forming
a fistula in  ano, eight months after being eaten.
Memoirs of the Medical  Society of London. V.
154.  1796.
   Blair, (Wm)   Case of a piece of hard toast
arrested in  the anus, and extracted by forceps.
Medical Facts and Observations. VI.
   \ 5. Prolapsus Ant—called also Exanea
and Archoptosis.  This term has been ap-
plied, by surgical writers, to several distinct
accidents,  and it is  necessary, in order to
avoid confusion, that we should confine its
 signification within narrower limits.
   The different kinds of tumours formed by
 protrusions of one or more coats of intes-
 tine from the anus, may be arranged under
 four heads; first, invaginations of the colon,
 gradually elongated until an inverted por-
 tion  of the  gut appears externally;  the
 intussusception sometimes taking place so
 high in the abdomen that the coecum itself
 is presented (see Intussusception);  sec-
 ondly, invaginations at the promontory of
 the sacrum, the extremity of the  sigmoid
 flexure  of the colon  being received into 
ANUS. (Prolapsus.)                            97
the upper portion of the rectum, and finally
reaching the  anus (see Colon);  thirdly,
invaginations  of  the  superior portion of
the rectum itself into the inferior dilata-
tion or pouch of that viscus (see Rectum);
and lastly, eversion of the mucous coat of
the superior portion of the anal canal, and
the neighbouring portion of the rectum.
Some surgeons would add a fifth class of
cases; those in which all the coats of the
rectum are inverted  at the anus:  but al-
though we do not feel warranted in deny-
ing the possibility of such cases, we cannot
conceive how they can exist as a  primary
affection.  The close attachment  of the
posterior surface of the rectal pouch to the
parts about the os coccygis, and the still
more intimate connexion  between its an-
terior face and the prostate gland, and the
base of the bladder, must necessarily pre-
vent  any  inversion  at  this point  from
taking place, unless after long-continued
dragging has elongated the dense cellular
bands that oppose it; and such dragging is
only  likely to  occur as a consequence of
an old and neglected invagination of the
third named class.
  We shall consider  the term prolapsus
ani,  in this article, as applicable to the
fourth class of cases enumerated, referring
the reader, for further information as to
the other accidents, to the several heads
above mentioned, thus escaping the confu-
sion  likely to result from treating in one
article diseases or accidents  varying so
widely in  their seat, consequences, and
mechanical treatment
  In the  two preceding articles we  have
spoken of the amplitude of the mucous
membrane  near and within the anus; of
the laxity of the  cellular membrane that
binds it to the neighbouring coat of the in-
testine; of the arrangement of the reverted
muscular fibres of the longitudinal plane,
playing over the edge of the internal sphinc-
ter, as over a pulley;  and of the character
of the two sphincters, and the manner in
which they give support  to the lower ex-
tremity of the rectum, both when  at rest
and in motion.  Bearing  these things in
mind, it is easy to perceive the nature and
the causes of prolapsus ani.  The mucous
membrane covering the  upper portion of
the canal, is always everted, to a certain
extent at every stool, by the longitudinal
fibres.  Accidental irritation of these fibres
increases this effect.  In persons of costive
habit the faeces, by their strong  friction
upon  the membrane,  urge it still  farther
forward.   Frequent and excessive dilata-
tions of  the  sphincter  internus occasion
permanent enlargement of the canal, and
  VOL. II.          9
diminish the  resistance to the  eversion.
Irritation in the anus, the rectum, or any
part of the  urinary apparatus, which sym-
pathizes  strongly  with  these  parts, in-
creases  the evil by  producing  tenesmus.
At length these various causes may so far
elongate the cellular attachments of the
mucous coat as to permit a circular fold to
become permanently loosened, presenting
at the orifice of the internal  sphincter,
provoking  frequent and often ineffectual
attempts to go to stool, and occasioning
habitual distension and still greater loss
of tone  in  the part.   If hemorrhoidal, or
other tumours are not already formed, they
are now extremely apt to appear, in con-
sequence of the embarrassment of  the
circulation  in  the part produced by the
pressure  of the  sphincter  on  this  fold.
When present these tumours tend to pro-
mote the progress of the  misplacement,
for they not only offer additional resistance
to the passage of the faeces, but by be-
coming  entangled in the   grasp of the
sphincters,  they often keep the parts con-
stantly on the  stretch.
   On its first appearance,  prolapsus ani
generally presents but a small  tumour,
surrounding the anus like  a ring, during
the efforts at stool< and  retreating slowly
when those efforts cease.   It often shows
itself at certain periods only, during spells
of costiveness or diarrhoea, or during strong
and long-continued action of the abdominal
muscles; as in severe  fits of crying  in
children, and in protracted or difficult par-
turition.  But  if its progress remains un-
checked, it  soon becomes larger, reappears
at every stool, takes the shape of a globu-
lar or oblong mass, and no longer retreats
by the unaided powers of nature.  In this
condition, every stool produces an eversion,
not only of the mucous membrane of the
superior part of the  anal canal,  but the
integuments of the lower portions are also
drawn down, the  skin around the margin
is elongated and loosened, and even when
the prolapsed parts are returned, we often
find a considerable flap, or ring of redun-
dant skin  remaining externally, compli-
cated with  irregularities of the canal, and
very imperfect action in the sphincters.
   The accident occurs much more fre-
quently in  childhood and in old age than
during the vigour of life.   The extent to
which the  eversion may be carried in ex-
treme cases is prodigious, and it is  possi-
ble that in old cases, the mucous membrane
of the middle or upper part of the rectum
may be put upon the  stretch, so as to pro-
duce invagination of  the remaining coats.
   Among the occasional causes of prolap- 
98                           ANUS.  (Prolapsus.)
sus ani, not already pointed out we may
enumerate the  use  of aloetic purgatives,
the too frequent resort  to  emollient or
warm injections, paralysis of the sphinc-
ters, and  tumours  or thickening  of the
mucous membrane.  The symptoms are
generally milder than would be inferred
from the great  tenderness and the impor-
tant relations of the parts interested, for
the prolapsed membrane often bears ex-
posure almost with impunity.  In sudden
and very considerable eversions, however,
severe inflammation, violent pain, and fe-
brile symptoms appear;  and when stran-
gulation takes  place,  the discharge of
faeces is arrested, and all the phenomena
of strangulated hernia may  occur.
   When the prolapsus  is small  and re-
cent it is returned with ease, and its re-
currence may be  generally prevented by
suitable mild measures; but when it  is
large,  or  habitual,  it  is replaced with
greater difficulty, and can be relieved per-
manently only by surgical treatment of a
more serious character.  If the cause which
excites it is incurable, as  sometimes hap-
pens when irritations of the prostate gland,
bladder, or urethra,  produce tenesmus and
consequent prolatpsus, the ultimate cure is
out of the question,  and we can only tem-
porize  and palliate.
   The treatment of prolapsus ani has a
double purpose; firsttne reduction or re-
turn of the  prolapsed part, and secondly,
the prevention of a recurrence of the ac-
cident ; to which we may perhaps add a
third, the removal  of the prolapsed part
when rendered  irreducible.
   The reduction, when there exists nei-
ther strangulation nor inflammation, and
when it is not  accomplished by assuming
a horizontal posture, or by the unaided ef-
forts of the  patient, is generally effected
with great facility by the surgeon.   The
patient being placed in bed,  with the pel-
vis raised and the abdominal muscles re-
laxed as much as possible, the surgeon, if
the tumour  be  quite small, embraces  it
with the palm of his hand, previously oiled,
and makes gentle pressure upon the whole
surface, for  some minutes,  if necessary.
The blood accumulated  in the tumour is
thus gradually driven back into the pelvis,
the swelling is  diminished, and the reduc-
tion is  generally accomplished with great
ease. There commonly remains, however,
some laxity of the integuments about and
within the canal; and  in order to insure
that the last portions of the mucous mem-
brane are returned within the orifice of
the internal sphincter, it is advisable to
apply the  thumbs, or the  two indices, to
the sides of the anus,  so as to press the
skin inward, and then, by introducing a
well-oiled finger within the  rectum, we
may remove any folds or irregularities that
might otherwise keep the cellular tissue on
the stretch,  or prove a source of irritation
to the rectum.  When the tumour is very
large, it cannot be  returned by so simple
a proceeding, and it becomes necessary to
roll the prolapsed membrane  toward the
orifice of the intestine in the middle of tha
tumour, by  means  of the fingers;  thus
gradually reducing the swelling by return-
ing, first the portions last discharged.  In
extreme cases, this is often a task of great
difficulty; and the inexperienced operator
should  bear in  mind the fact  that the
membrane may be  returned within itself,
without entering the canal;  or,  in other
words, that the part of the tube which es-
capes last, may be folded within the por-
tion which should line the lower part  of
the rectum, without  passing the sphinc-
ter ; and may thus increase the difficulty
of reduction, while  the  surgeon thinks
that he is gaining  ground.  The efforts
at reduction should  never be forcible  or
rough;  and while  the fingers are em-
ployed in involving the tube, it  is  often
proper   to keep up  a moderate  general
pressure on the tumour, with the palms
of the hands.
  If considerable difficulty is  experienced
in effecting a reduction, some further mea-
sures may be proper; as when the bowels
have not been  evacuated for a consider-
able time, or when they are known to be
in a costive condition,  and especially it
there is any tenesmus.  Under such cir-
cumstances, an  injection of castor oil oc-
casionally proves highly serviceable, for
when the rectum is in action, the presence
of firm  faeces opposes a powerful barrier
against  the reduction.  When the sphinc-
ters are called  into  spasmodic action, and
produce stricture, a free bleeding from the
arm may be indicated, if the  constitution
of the patient will warrant the measure;
but one of the most  powerful  means  of
combating spasm, is warmth.   The warm
hip-bath, warm mild  poultices and injec-
tions, will very generally answer the pur-
pose ; but when the spasm is severe and
obstinate, opiates should be added to these
applications. In cases  of actual inflam-
mation  of the prolapsed membrane, it is
very improper  to resort  to  frequent  or
strong efforts at reduction; and here it is
obvious  that the warm  applications,  even
when 6pasm is present, may become highly
injurious.   The "treatment plainly  indi-
cated is the  free employment  of leeches,
and  cold  poultices,  until the  swelling
and inflammation decline, after which we 
A1MJS. (Prolapsus.)
99
should again endeavour to return the pro-
truded membrane.  Sometimes the spasm
of the sphincter becomes so severe as to
close the outlet,  not  only  arresting the
faeces, but producing strangulation of the
prolapsed membrane,  and  then  all the
symptoms and the worst consequences of
strangulated  hernia  may be  presented.
The same result may occur without spasm,
from the mass of the tumour, when swelled
by inflammation.  In either of these cases
the seat of the stricture must be ascertain-
ed, and there could be little question as to
the  propriety of dividing the sphincters,
if necessary, by a suitable instrument; but
it is well perhaps to remark that in this
accident as in hernia, injury may be fre-
quently done by undue haste.  In recent
cases, the symptoms are often urgent and
require very prompt treatment, but in old
habitual prolapsus, the danger of strangu-
lation is seldom imminent.  We have re-
turned a most extensive prolapsus, which
was in a state  of high inflammation and
so constricted as to render discharges im-
possible for three days, without resorting
to any unusual measure, and without any
serious  consequences.   The variety of
sources, both internal and external, from
which the anus receives its supply of ar-
terial blood, and the peculiar arrangement
of hemorrhoidal veins, some of which tra-
verse the sphincters, and anastomose ex-
ternally, tend very greatly to diminish the
danger  of a total arrest of circulation.
When gangrene of the prolapsed part has
taken place, the question arises whether
the case should be left to the  powers of
nature  or be decided at once by the knife
or ligature.  The authority of Mr. Samuel
Cooper is in favour of the  former mode
of treatment (Diet, of Pract. Surg.  Art.
Anus); but this subject will be more fully
discussed when we come to speak of the
treatment of irreducible prolapsus ani
  The prevention of a recurrence of pro-
lapsus ani, is a department of practice too
much  neglected by writers.  The  mea-
sures employed for this purpose  may be
classed naturally under two heads; firstly,
the accomplishment of a radical  cure by
the removal of the causes of the accident,
and secondly, the prevention of prolapse
by mechanical means, when the causes
cannot be removed.   The surgeon is cul-
pably negligent of his duty, if, after re-
ducing a prolapsus ani, he fails to inquire
into  the habitual condition of the bowels
of his patient, to  ascertain, by inspection
if necessary, whether there  exists any tu-
mour, ulcer,  thickening or irritation in or
about the anus, and whether the sphinc-
ters  are permanently relaxed or dilated;
nor is it less important that he should de-
termine the healthy or diseased condition
of the urinary and uterine organs. If the
rectum  is in an  irritable condition, as is
very generally the case in children labour-
ing under this cpmplaint, the error of re-
gimen, or the diseased action, upon which
that irritability depends, should be  re-
moved as speedily as possible. In children
with  prolapsus from this cause, a cure
may be  effected almost invariably; but in
adults, when the  accident is produced by
rectal irritation, it is too frequently compli-
cated with scirrhus,  cancer, or other dis-
eases of the rectum, which, if at all cura-
ble, yield  only to  terrible surgical opera-
tions (see Rectum), and consequently the
radical  cure cannot often be attempted
with much hope of success.  When, how-
ever, the irritability of the rectum depends
upon ulceration, stricture, spasm, or an in-
vagination,  it may be sometimes effectu-
ally  relieved.   If sluggish action of  the
rectum, or costiveness, be the cause of the
prolapsus, the habit must be conquered, if
possible; and as the  causes of costiveness
are very various both in  their nature and
sphere of action,  we cannot pause to con-
sider the measures by which that end is to
be accomplished in particular cases. (See
Constipation.)  Dr. Physick has succeed-
ed in some cases in completely curing pro-
lapsus ani by confining his patients exclu-
sively to a  diet of rye  mush  and sugar,
and the same remedy has proved equally
beneficial in the hands  of other practi-
tioners.  (Dorsey's Elements of Surgery.
II. 169.) This sluggishness of the rectum
is perhaps the most frequent cause of pro-
lapsus in advanced life.
  If any tumours, ulcers, &c., be found in
the anus, they should be immediately treat-
ed.   We shall enlarge upon this subject
in the future sections of this article, and
in that on hemorrhoids. When the sphinc-
ters  are found dilated, recourse should be
had  to the  measures pointed  out in  the
section  on atony  of the anus;  but it may
be well  to remark that the local applica-
tion  of  a stream of cold water, by  the
douche ascendante, or otherwise, so highly
useful in this condition of the parts, is also
very serviceable  in giving tone to  those
more deeply seated; and  wherever  the
circumstances of the case do not prohibit
its employment, it will be found a power-
ful auxiliary in effecting the radical cure.
When the relaxation of the sub-mucous
cellular tissue is  extended to a consider-
able  distance within  the rectum,  cold and
astringent injections are used with great
advantage.  Mr. Hey recommends strong-
ly, for this  purpose, a  decoction of oak 
100
ANUS. (Prolapsus.)
bark, with alum and vinegar. (Pract. Obs.
on Diseases of Lower Intestines.)
  When prolapsus ani has occurred very
frequently, and during a course of years,
the cellular  tissue beneath the  mucous
membrane and  the integuments  within
and around the anus, become permanently
elongated to a great extent and the slight-
est causes then suffice to reproduce the
accident   Even assuming the erect pos-
ture sometimes occasions the prolapse un-
der such circumstances.  Constant disten-
sion resulting from the presence of the tu-
mour, then destroys the tone of the sphinc-
ters, and enlarges and thickens the integu-
ments of the middle and lower portions
of the anal canal, which, instead of a sim-
ple evolution, such  as sometimes occurs
in severe tenesmus, or more constantly in
recent prolapsus, now undergo an actual
inversion.  It happens not unfrequently,
in such  cases, that though the  mucous
membrane may be returned and retained
for a  time within  the internal sphincter,
the inverted integuments below the edge
of that muscle cannot be secured in their
proper place for an  instant, as was very
obvious in the first patient upon whom
Mr. Hey performed the operation which
will be presently noticed.   In this state
of things, the lower edge of the internal
sphincter corresponds nearly  or exactly
with the margin of the anus, the external
sphincter is half dilated, and opposes very
imperfectly the  tonic  contraction  of the
fibres of the  levators,  and the anus is
placed very much  in the  situation which
it assumes when subjected to an ineffectual
effort at stool.  The  lower portions of the
canal  no longer exist, and therefore the
inverted and enlarged integuments, if re-
placed at all, must be returned within the
superior  portion of the canal, where they
were never designed to enter, and where
their presence would be no more tolerated
than would a suppository, or  a mass of
faeces. The loose flap of integument, there-
fore, remains  hanging around the anus,
and the  hemispherical eminences seated
at the base of the columns of the rectum,
as described in the preceding  anatomical
article, present on the inside of the flap,
producing those blue tumours mentioned
by Hey and others, as visible  externally
in such cases.  Here it is evident that the
surgeon, instead of endeavouring to return
the flap, and  to support it by mechanical
contrivances, should  direct his efforts to
accomplish a  closer adhesion in the sub-
tegumentary cellular tissue in and  about
the anus, and, moreover, to effect this, if
possible, while the margin of the internal
sphincter  is restored to  its proper level
and  there retained, so that the adhesions
may take place while the mutual relations
of the parts are correctly preserved.  The
former of these indications has been ex-
plained by several  eminent practitioners,
and various operations have been devised
for its fulfilment; but the latter has  been
treated with apparent neglect.  The ear-
liest notice that we have seen of the plan of
removing portions of the dependent flap
for the avowed purpose of creating adhe-
sions between the integuments and the
deeper-seated parts, in order to effect the
radical cure of these old cases, is contained
in Cheselden's Anatomy, though his di-
rections, and his sound pathological reasons
for them, have been overlooked by his suc-
cessors, who  have  claimed originality for
processes not always as well adapted to
the end in view.   Speaking of the condi-
tion  just described, Cheselden remarks,
" This case I have cured by taking away
a piece of the prolapsed gut with a caustic,
lengthwise of the gut;  the  wound dis-
charged  the flux of humours,  upon which
the gut was easily reduced, and cicatrizing
in that state, it never  more  fell down."
(Anat. ed. 13. p.  158.)   Mr.  Hey some-
times resorted to a much more formidable
operation than that of Cheselden, for the
purpose,  as he states, of bringing about
a  firmer  adhesion  to the  surrounding
cellular  membrane, and to increase the
contraction of the sphincter. (Pract. Obs.
&c., ed. 2. p. 438.)   This operation con-
sisted  in the  amputation  of the whole
dependent flap, or, in  other  words, the
removal of the whole  natural lining mem-
brane of the middle and lower portions of
the anal canal.  In one instance, indeed,
he says  expressly  that  he also excised
about one-fourth of an inch  of the red
lining (i. e. mucous membrane) of the in-
ternal  sphincter.   He gives five cases, in
the first and third of which this operation
was performed, and the patients were ulti-
mately cured by it.  The only important ac-
cidents that resulted from this violent mea-
sure  were symptoms threatening peritoni-
tis, and returns of the prolapsus, the latter
sometimes occasioning great difficulty du-
ring the progress of the cure. In the second
case, the patient had enlargement of the
tubercles of the middle region of the anus;
the prolapsus was inconsiderable in extent.
The  tubercles were removed  on one side
only, and by the aid of astringent applica-
tions, the patient recovered.   The fourth
case was one  in which the inverted mu-
cous membrane had formed extensive ad-
hesion with the external integuments on
one side of the anus.  At the suggestion
of Mr. Lucas, these  adhesions were dis- 
ANUS. (Prolapsus.)                          101
sected, and the tumour was returned. The
patient refused to submit to any further
operation, and, although he experienced
considerable  relief, the radical cure was
not accomplished.   The fifth and last was
that of a lady, who had suffered for many
years with a considerable prolapsus, reap-
pearing on the slightest exertion;  one of
the tubercles was  removed  on  each side,
and the cure was so perfect that no further
inconvenience was experienced. The first
of these cases is  dated in the autumn of
1788; the last in  June 1799.
   This operation appears to have  origin-
ated with  Mr. Hey.  Leonida, according
to ^Etius, Fabricius ab Aquapendente,
and Riolanus the elder, mention the de-
struction  of the prolapsed part  by  actual
cautery, as a means of cure; and Severi-
nus defends it by many observations of his
own;  while Blegny and Dionis very rea-
sonably contend against it. (Morgagni De
Sed.  et  Cans. Morb. ep.  xxxiii.  art 2.
obs. 10.)   There is also an observation of
Cowper, in which the prolapsed part mor-
tified and was  excised, and  the accident
occurred no  more. (Anatomy of the Hu-
man  Body, 601.  t 39. f. 7.)  B*c these
facts  do not militate against ths claim of
Mr. Hey. The operation has keen success-
fully  performed in this country by  Dr. J.
W. Heustis.  (Amer.  Journ.  Med.  Sc.
XI. 411.)
   Whately, in a paper published in 1800
(Med. Facts and Obs. VIII.  163. Lond.),
gives  an  account  of a highly interesting
case, which he attended in company with
Mr. Cline.  Portions of the flap were ex-
cised, but the prolapsus still  recurred; the
operation was again repeated, but the tu-
mour reappeared with the first stool.  An
attempt was then made to  prevent this
accident until the parts could cicatrize, by
the introduction of a piece of tallow-candle
into the anus, but it melted.  A portion
of a wax-candle was then substituted, but
it speedily determined a stool, which of
course expelled it, and no benefit resulted.
The whole of a wax-candle, secured by a
string, was then  introduced  entirely into
the rectum, on the  fourth day  from the
last operation; the bowels were calmed by
an  opiate,  and  the string left  suspended
from the anus; the prolapsus returned  no
more.  The candle was retained five days,
and when withdrawn, the wax had  disap-
peared; the  wick alone  remaining.  In
1802, Mr.  Howship saw Mr. Heavyside
operate by ligature upon  a  case of piles,
complicated with prolapsus; both diseases
were relieved by the single operation. Mr.
Howship states his belief that the  opera-
                  9*
tion  for hemorrhoids by ligature will al-
ways cure a coexisting prolapsus, if it be
rightly conducted, and  if the consecutive
treatment be properly  managed.  He ad-
vocates the application of a ligature  to
provoke the adhesion  in all cases of pro-
lapsus, and reprobates the use of the knife
and scissors, asserting that in his own and
Mr. Heavyside's extensive experience he
has known the latter to fail, but not the
former.  Where no piles exist he recom-
mends taking up a  portion of the smooth
lining of the anus by the tenaculum, and
inclosing it in the ligature. (Pract.  Obs.
on Diseases  of the  Lower  Intestines, ed.
3. p. 163.)  Mr.  Dupuytren was led by
the frequent  cure of prolapsus by the ex-
cision of piles, to  imitate this operation in
cases unattended by tumours.   Formerly
he cut away  portions of the inverted mu-
cous membrane,  but was deterred  from
continuing this plan by one case of conse-
quent hemorrhage,  and another of obsti-
nate suppuration.  He then  adopted a
different course, which consisted in remov-
ing a  certain number of  the  radiating
folds of the skin converging to  the anus;
these he seizes separately,  by a ligature
forceps somewhat flattened, and then cuts
them off from without inward,  by a  pair
of curved scissors.  In one case, where
the tumour measured ten inches by seven,
he succeeded completely by removing six
of these folds. (Journ.  Universel des Sci-
ences Medicales.  Sept. 1822.)
  The  object of  all the operations  just
noticed, is, or should be, one and the same;
namely, the creation of a cicatrix or adhe-
sion in the  sub-mucous and  sub-cutaneous
cellular tissue in and  about the anus, in
order that  the retraction or condensation
produced thereby may reduce  the canal
to its natural dimensions, and restore the
proper closeness of connexion between the
different parts that compose it   In cases
where  the  lining membranes are not un-
duly extended and thickened, but are  sim-
ply in a state of habitual relaxation,  it is
evident that  surgical  interference should
be confined to measures for the production
of simple condensation or agglutination of
the cellular  tissue  by adhesion, and all
loss of substance beyond what may be ab-
solutely necessary to  provoke this adhe-
sion, is not only  useless  but hurtful, for
the healthful play  of  the  various parts
composing  the anal  canal, cannot be dis-
turbed  without endangering the occur-
rence of some of  the numerous accidents
to which it is liable; and the substitution
of a cicatrix  for the original integument
must interfere with  this play. Old, habit- 
102                           ANUS. (Prolapsus.)
ual prolapsus of this simple character not
unfrequently yields to the treatment alrea-
dy  laid down  in the earlier part of this
article; but if they resist  this treatment
there are other agents at command, by
which we may sometimes provoke the
required condensation, without resorting
to the knife or ligature.  An endless va-
riety  of tonic  or  astringent applications
have  been recommended for this purpose,
and among these may be enumerated injec-
tions  and ablutions of a strong decoction
of  oak-bark and  lime-water,  as  recom-
mended by Mr. Hey; the  application of
pledgets wet with a solution  of sulphate
of zinc, or other mineral astringents, as
advised by Mr. Cline (Whately, op. cit.);
or injections of tonic vegetable decoctions,
mingled with spirit of wine, or other direct
stimulants, as .employed by  many  prac-
titioners.   We have  succeeded  several
times in curing prolapsus which had con-
tinued for a considerable period in delicate
females, in  whom the  disease was  pro-
duced by painful  menstruation,  by the
exhibition of fifteen drops of spiritus tere-
binthini, given  in  the usual form of mix-
ture three times a day, and continued for
several weeks, the dose being  varied in
proportion to the  effect produced on the
bowels, in each individual case.
  This remedy produces considerable irri-
tation about the anus, without calling the
rectum into strong action;  and the irrita-
tion is concentrated almost entirely upon
the middle and lower  part of the anal
canal, and the surrounding skin; the very
spot where its production is properly indi-
cated.  It is advisable to administer  it
internally, in  preference to applying  it
locally, because it effectually  regulates
the bowels,  thus fulfilling two purposes
at  the same time.  The existence of a
purulent or sanguineo-purulent discharge,
does not interdict its use, when the consti-
tution of the patient  and the absence of
other diseases admit it
   When such measures have failed,  then,
and not till  then, the employment of sur-
gical  means  becomes requisite; but the
object in these simple cases, being merely
the creation of adhesion in the relaxed
cellular tissue,  it would be very wrong to
resort to any of the more severe operations
enumerated above.  We will then con-
sider,  firstly, the  situation in  which the
adhesions are required; and secondly, the
means of producing them.
   The relaxation which  produces the ac-
cident takes place, originally, at the lower
part of the superior portion of the canal,
where the reverted longitudinal fibres of
Horner  exert  their action;  but it ex-
tends itself also  to the lower  portions of
the canal, and the neighbouring  surface.
While the last-mentioned parts continue
displaced, the adhesion of the margin of
the mucous membrane to the edge of the
internal  sphincter,  even if it could  be
effected, would only  partially relieve the
difficulty, and the advantage gained would
be evanescent, because of the absence of
the natural support furnished by the lower,
to the upper part of the  canal.  It  is,
therefore, of  the highest  importance to
effect the required adhesions in the parts
below the edge of the internal sphincter.
But this is not all; for, if the laxity of the
cellular connexions were allowed  to  con-
tinue unaltered in the superior portion of
the canal, the original stage of the disease
would  still continue, and  the accident
would  reappear,  upon the recurrence of
the causes which first produced it  It is
desirable, then, that  the  adhesions should
continue beyond the margin of the internal
sphincter; but it is by no means necessary
that they should  extend far beyond this
line; for, if a consecutive prolapsus were
to occur  higher up in the canal, it would
be a prefer invagination of the membrane;
an accident not likely to occur, unless in
some very rare cases of tumour; one which
the history of *he disease does not lead us
to anticipate, and  which the natural action
of the parts  in  defecation  (see Art II.)
strongly tends to  prevent If it were even
desirable to create the adhesions through-
out the whole extent of the lax cellular
tissue, it would still be scarcely possible;
for the relaxation often extends high  into
the rectum in old cases, and  experience
proves that when the parts about the mid-
dle of the anus are restored to their proper
relations, the  prolapsus returns no more.
So much for the  required location of the
adhesions: as to  the means of producing
them by  surgical operation,  there  is j.
choice. The principle adopted by Chesel-
den, and mentioned above, is decidedly the
best, though his  operation admits of im-
provement.   The portion of tegument re-
moved should equal in length the extent
of the required adhesions; that is, it should
begin upon the  skin at  a little distance
from the  margin of the  anus, and should
terminate upon that  part of the  mucous
membrane, which, when fully reduced,
would be applied  at, or a little within, the
margin of the sphincter; its  breadth, in
these cases of simple relaxation, cannot
well be too narrow; for  it is desirable to
leave the parts, after the cure, as  little as
possible embarrassed by cicatrices, or lim-
ited by permanent contractions.  Chesel-
den's mode of operating by caustic  appears 
ANUS. (Prolapsus.)
103
to have been entirely abandoned, although,
in very careful hands, it might, perhaps,
prove better  in some respects than either
the knife or  the ligature.   The removal
of a single slip of integument as advised
by this author, seems to be hardly likely
to effect adhesions of sufficient extent, for
it is desirable that they should take place
round  the whole circumference  of the
canal.   The  plan of  M. Dupuytren is
preferable, in this respect as  the  length,
number, form, and width of the strips re-
moved, are varied according  to the exi-
gence  of the case; and the bruising pro-
duced  by the scissors prevents union by
the first intention, which is evidently to
be avoided in such operations. The method
by ligature, as recommended by Mr. How-
ship,  is liable to  two very strong objec-
tions:  firstly, it  cannot be employed in
such a manner  as to act on  a long and
narrow surface;  and secondly, it is in-
tensely painful, for it is absolutely neces-
sary that  the ligature should embrace a
portion of true skin, and the sensibility of
the part  is such as to render this agoniz-
ing,  and  almost  unendurable (see § 9,
on tumours of anus).   The united testi-
mony of Howship and Heavyside in fa-
vour of the universal success of the ligature
is, therefore,  hardly sufficient ground for
recommending this operation;  for the duty
of the surgeon is not confined to effecting
a cure; he is equally bound to effect it in
the best manner, with the  least inconve-
nience to his patient.  The only advantage
possessed by the ligature over the scissors
or knife, is the avoidance of all  hemor-
rhage ; but in superficial operations upon
the lower portions of the anal canal, the
danger of considerable hemorrhage is very
small, and if it should even occur,  it is
now commanded with great ease.   Even
the aid of the speculum ani  isnot required
to detect a bleeding vessel at or below the
margin of the internal sphincter.  If we
might be permitted to throw out a sugges-
tion prompted by the  study of the anatomy
and physiology of the anus, but the value
of which has  not yet been practically test-
ed, we would propose, for the relief of these
simple cases, an operation unattended with
any appreciable loss of substance, while it
would secure the required adhesions. It is
this: Let two or three simple  incisions be
made with a small scalpel, on each side
of the  anus,  beginning on the protruded
membrane (which, when in situ naturale,
lies a little within the sphincter), and ter-
minating on  the skin, about half an inch
from the margin of the  anus.   These
incisions  should   be  carried  completely
through the tegumentary membranes, but
need not extend beyond them. They should
follow the summits, and not the  intervals
between the radiated folds of the margin,
as wounds  in the latter situation are very
apt to degenerate into troublesome exco-
riations or ulcers.  The edges of each in-
cision should be touched very lightly and
quickly with nitrate of silver, so as  to se-
cure them against immediate  union. This
plan would be much less painful, and, if
successful, would restore the relative po-
sition of the  parts more  completely than
either of those above mentioned.
  When prolapsus ani is complicated with
tumours, the measures necessary for the
removal of those tumours determine adhe-
sions  in the neighbouring cellular tissue;
and, if  proper care is taken  before and
after the operation, to secure  the coapta-
tion of" the parts, a radical cure will almost
always result: the very strong testimony
of Howship alone would be sufficient  to
warrant this  assertion.  While speaking
of tumours,  however,  it  may  be well  to
remark, that the tubercles  so often men-
tioned by Hey and others, being a natural,
and not a morbid appearance  as has been
supposed (see Art. 1. Anatomy of  the
Anus),  do not  require  removal,  unless
they are so far enlarged by disease, as to
interfere with the proper contraction of the
external sphincter; and, in determining the
propriety of removing them, we should be
careful to distinguish between permanent
enlargement, and the mere  temporary
swelling that occurs from fullness of the
vessels during a hemorrhoidal flux, or an
embarrassment of the venous circulation
of the part by mechanical causes; the for-
mer of which can be relieved only by gene-
ral  treatment, and the latter, by replacing
the parts, and  obviating  costiveness, or
spasm, if present.
  When the constant repetition of the
prolapse, and the bulk of the tumour have
produced permanent thickening, and actual
hypertrophy of the displaced  membranes
and skin, it  becomes absolutely necessary
to remove a more or less considerable por-
tion of the lining of the anus, and to make
use of the contractile power  of the cica-
trices, to diminish the diameter of the en-
larged canal; else, the sphincters  could
never recover their proper position, and
the radical cure  would be out of the ques-
tion.  To accomplish this, perhaps no ope-
ration promises so fairly as that employed
by Dupuytren, because of the great facility
with which the form of the excised parts
may be adapted to each particular case.
Notwithstanding the  very high respect
which we always feel for the authority of
Mr. Hey, we are compelled, on the present 
104
ANUS. (Prolapsus.)
occasion, to object to his mode of operating,
as unphilosophical  in principle, and very
liable, in many cases, to  produce most se-
rious consequences.   It is unphilosophical
in principle, firstly, because it professes to
induce a tonic contraction of the sphincter,
by creating adhesions between it and the
integument;  that  is, it requires a cicatrix
to perform the function of a muscle; and
secondly, because  it removes entirely the
natural lining of the two lower portions of
the  anal canal, and substitutes for them,
partly a proper mucous membrane not de-
signed to exist in that situation, and partly
a  cicatrix  inclosing  the whole  circum-
ference of the anus, and incapable of un-
dergoing, without injury,  the  dilatations
necessary in  defecation.   In proof of its
liability to  produce serious consequences,
we will quote the  testimony of one of the
fathers of English surgery.  Cheselden
says he saw a case where a bold unthink-
ing surgeon having cut off the prolapsed
part, the cicatrix  was so  hard and con-
tracted that the patient could never go to
stool, without a clyster, and then not with-
out great misery. (Loc. Cit.)  It is singu-
lar that Mr. Hey should make no remark
on the advice  of Cheselden, as the work
of the latter was  in  the hands of every
student at the period of his studies.  Jus-
tice, however, demands that it should be
remembered that  Mr. Hey used  this for-
midable operation  only in  certain cases;
but even in these, the prolapsus was not
irreducible; and it is only when the re-
turn of the prolapsus is impossible, that
we could entertain for a moment  the idea
of a complete amputation  of the tumour.
  Prolapsus ani may become irreducible;
but we do not consider in this light those
cases in which the tumour simply forms
adhesions with  the surrounding integu-
ments so as to oppose the reduction; as
was  observed  in Mr. Hey's  fourth case;
for these adhesions may be divided.  Nor
would we term those cases irreducible, in
which the thickened or contracted sphinc-
ters prevent the return, for these also may
be,  and have  been, successfully  divided.
But when the  folds of inverted membrane
become fused together, or when condensa-
tion around the whole margin of the anus
opposes the recession of the tumour, it
sometimes  becomes impossible to return
it, even by an operation.   In these irre-
ducible cases,  the purulent or sanguineo-
purulent discharge, so common in old pro-
lapsus, becomes extremely exhausting to
the patient and is, moreover, so horribly
disgusting  and distressing, that life on
such terms is rendered undesirable. Here,
 if no other measure of relief can be em-
 ployed,  the  amputation of the prolapsed
 part may prove a correct practice in the
 last resort; it is a situation produced only
 by culpable neglect on the part of the pa-
 tient or  his surgeon.  If the tumour is not
 very large, the projecting membrane may
 become  changed in structure with time,
 assuming somewhat the  character of the
 cutis, and becoming invested with a cuticle,
 according to a well-known law of the ani-
 mal economy.  We have seen one very
 remarkable case of this character.  When
 such a disposition is displayed by the dis-
 placed surface, and the circulation in the
 part is not threatened,  it would be wrong
 to  amputate,  particularly as these cases
 generally occur late in life, when there is
 no longer occasion for great or dangerous
 exertion; and the changes should be fa-
 cilitated by avoiding the use of poultices,
 and by keeping  the part as dry and as
 much  exposed as is consistent with safety
 and comfort. Among the  accidents which
 may compel us to amputate the prolapsed
 part when irreducible, we may mention
 the occurrence of dangerous hemorrhage
 from  the surface;  though this is more
 likely to happen in recent cases,  before
 the character of the membrane is changed.
   Having  now completed this rapid view
 of  the various modes of radical cure, it is
 necessary to add some remarks upon the
 preparatory and subsequent treatment ne-
 cessary to give the greatest possible effi-
 ciency to our efforts, whatever operation
 may be preferred.  In the  first place, it is
 highly desirable that the  anus should re-
 main at rest, during the reunion of the in-
 cisions,  and, if possible,  until the adhe-
 sions  have acquired some firmness;  this
 requires several days.  A week or two be-
 fore the operation, then, we should exert
 ourselves to regulate and preserve the
 natural operations of the bowels, in order
 to place  the part in the most favourable
 condition.  This  being accomplished, if
 the  patient's constitution permits,  we
 should place him  upon the simplest diet,
 preferring such viands as are least likely
 to distend the bowels with feeces; and this
 diet should be observed, if possible, for a
 week or two after the operation.  On the
 day of the operation, the  rectum should
 be  carefully emptied, some hours  before-
 hand, by means of mild enemata, calcu-
 lated  to  act on the lower part of the ali-
 mentary canal alone—and about one hour
 before  the performance, a full dose of lau-
 danum, or  the acetic tincture of opium,
should be given, with a view to arrest the
action  of the bowels.   Opiates should be 
AIM US. (Prolapsus.)
105
occasionally exhibited, after the operation,
to prevent any  attempt at discharge, so
long as the state of the patient and the
nature of the diet will permit. The next
important matter is to place and keep the
parts as nearly as possible in their proper
relative position,  during the cure.   For
this purpose,  the patient  must be placed
in the recumbent posture, and ought not to
leave it, until the expiration of at least a
week, except under urgent necessity. His
pelvis and knees should be somewhat ele-
vated, and his shoulders comfortably sup-
ported.   While  in this  position, the sur-
geon should assure himself that the reduc-
tion  is  perfect  and for this purpose,  he
should introduce his  finger, if necessary.
   If the parts, from great laxity, are not
retainable without assistance,  it may be
proper to  retain them, in the first instance,
by a graduated  compress, and a crucial
bandage secured to a band round the pel-
vis. The patient must be strictly watched,
and if there is a return of prolapsus from
any cause, it should be replaced as speedily
as possible. This accident is the more un-
fortunate  as it occurs later after the ope-
ration.  When the patient leaves his bed,
the adhesions are not to be considered as
having  acquired  their full firmness,  for
this requires some time; and the diet and
condition of the bowels must be watched
with great care, for a longer period.
   One  more  remark in conclusion.  The
atony of the sphincter externus being ha-
bitual in most cases, is  not and cannot be
cured by  the operation,  and would,  if
neglected, lay the foundation of a relapse.
It is therefore highly important to invigo-
rate it as speedily as possible,  and  the lo-
cal  application  of cold for  this purpose
may commence in most  cases soon after
the operation, before the patient leaves his
bed.  When  he has risen, the stream of
cold  water, so strongly recommended in
the earlier part of this article, should be
fully insisted  on.
   When, in  reducible prolapsus, the pa-
tient or the surgeon decides  against at-
tempting the radical cure by operation,
there are still certain mechanical means of
support that tend to prevent the frequent
return of the protrusion.  Some of these are
employed internally, and the others exter-
nally.  The general objection against  the
former, is the necessity of leaving part of
the ligature in the anus to control the body
introduced within the rectum, and we know
of no apparatus yet contrived that  can be
allowed to remain during an evacuation,
at  which time  prolapsus is  most likely
to happen.  The oldest  of these, and one
of the best in principle, was  the  measure
employed by Bleony—who introduced into
the rectum, the craw of a turkey, which
was then distended with air through a sil-
ver tube attached to this membranous bag,
and left  suspended from the anus. (Uart
de guerir  les hernies.  p. ii.  s. 2.  c. 8.)
Callisen (Syst. Ch. torn. H.) employed a
piece of sponge secured by a silver probe,
and introduced into the rectum.  Riche-
rand (Nosogr. Chir. III. 444.) used a plug
of lint inclosed in fine linen and supported
by a  T bandage,  for the  same purpose.
Dr. Sims recommended a globular ivory
pessary (Whately. Op. Cit.), and more
recently, instruments of the same charac-
ter,  but  made of  gum  elastic,  have ac-
quired a reputation in France.   All these
substances must be evacuated, or with-
drawn at nearly every stool although some
of them  are perforated avowedly for the
passage of faeces,  and therefore, the dis-
gust  of  frequent  reapplication  is super-
added to the great  uneasiness, and perhaps
injury, that their  presence in the rectum
must produce.  Still  there  is  evidence
enough to show that they  are occasionally
serviceable, and possibly some contrivance
may  be  hereafter  invented  that  may
cause less inconvenience, and permit of
alvine evacuations without requiring a re-
moval.  There is  much  less objection  to
those dressings that act by giving support
externally, and  of these, one of the best
is the  graduated   compress  and  crucial
bandage already mentioned, when discuss-
ing the proper treatment after operations;
for it is scarcely necessary now, to notice
the  hollow rings,  and other  similar con-
trivances recommended by Riolanus, Di-
onis, Murolt, &c, which have long since
disappeared  from practice.  (See Mor-
gagni. Epist. Cit. Art 8. obs. 7.) Mr. Gooch
has published an account,  with a figure, of
a very well-contrived  instrument  which
he employed with signal advantage in an
interesting case.   It is a species of truss.
The  upper part resembles the spring and
main  strap  of  a  common double truss,
wanting the pads, and is designed to em-
brace the  sacrum and  the wings of the
ilii.   Opposite the base of the lumbar ver-
tebra, a curved spring is attached, at right
angles, to the upper part, and after follow-
ing the curve of the sacrum, it terminates
in a pad intended to act upon  the  anus.
This gives firm support, and may be turned
aside without difficulty when at stool.   It
may be rendered very secure by scapula-
ries, &c.—and the patient may  use  exer-
cise, or  ride on  horseback with perfect
safety.
   If we have been minute in some of the
practical directions just given, it is because 
106
ANUS.  (Inflammations.)
 we are firmly persuaded that the want of
 success in a majority of unfortunate sur-
 gical  cases results  from  the  neglect of
 what may be termed by some, petty details
 of treatment  The minor duties of the
 surgeon are often quite as important as his
 more imposing operations.

   Bibliography.—Leonida apud Mtwm.  Te-
 trab.  IV. serm. ii. cap. 7, 8.
   Pare (Ambroise.)  Les QSuvres de.  L. xxiii.
 c. 65. 4to.  Paris, 1651.
   Severinus, (M. Aurelius.)  Quoted by Mor-
 gagni.  Epist. xxxiii.
   Blengy, (M.)  L'Art de guirir les  Hernies.
 Paris.  Quoted by Dionis.
   Cowper.  Anatomy of the Human Body.  P.
 601. t 39. f 7.  Oxford, 1698. fol.
   Dionis. Cours d'Opiralions de Chirurgie. Pa-
 ris, 1707 a 1714. Ed. i 8vo. par La Fa ye, p. 392.
 eL seq.  Paris, 1740.
   Verduc.  Pathologie de Chirurgie. II.  Amst
 1717.
   Cheselden.  Anatomy of the Human  Body.
 Lond. 1741.  Ed. 13. 8vo. p. 158.  Lond. 1792.
   Monro, (Alex.;  Essay on Procedentia Ani,
 in Edinburgh Physical and Literary Essays. II.
 353. (1756.)
   Morgagni.  De Sedibus el Causis Morborum.
 Epist. xxxiii.  (1760.)
   Smellie. A Treatise, with a Collection of Cases
 and  Observations in Midwifery.  I. 415.  ed. 5.
 III. 8vo.  London, 1776.
   Bosc.  Dissertatio de Venesectione in Puerpe-
 ris.  P. 27.  Lips. 1768.
   Gooch. Medical and Chirurgical Observations.
 London, 1773.  Also Chirurgical Works, 3 vols.
 London, 1792.
   Sabatier.  Mimoire sur les Anus contre na-
 ture ; in Mimoires de I'Acadimie Royale de Chi-
 rurgie.  V. pt. 3. alias torn. XV. ed. in 12mo. p.
 31. et seq.  Paris, 1774.
   Kerstens.   Hisloria Sedis  Prosidua,  resec-
 tione feliciter sanata.  Kilon, 1779.
   Art Anus,  Chute de V., in Encyclop^die Me-
 thodique.  Paris, 1790.
   Latta.  System of Surgery. II.  Edinburgh,
 3 vols. 8vo. 1795.
   Richter.  Anfansg. der Wundartzn. 73. VI.
 403. ed. of 1802.
   Hey.  Practical Observations in Surgery. Ed.
 3-  London, 1814.
   Whately. In Medical Facts and Observations.
 VIII. 163.  London, 1808.
   Bell, (Charles.) System of Dissections. Ed.
 3. tab. 10. 2 vols, in 1.  London, 1809.
   Chevalier.   On Relaxed Rectum.  In Medi-
 co-Chirurgical Transactions.  X. 401.  (1819.)
  Dupuytren. In Journ.  Universel des Sciences
 Midicales.  Sept 1822.
  Coulet, (M.)  Observations sur un Cas de
 Chute de Rectum—exaspiri par les imolliens, et
guiri par les astringens. Archives Generales.  I
487.  Paris, 1823.
  Richerand.  Nosogr. Chirurg.  Ed. 4. t. III.
  M'Farlane.  Case cured by Hey's  Method.
 In Glasgow Medical Journal.  i830.
  Cooper, (Samuel.)  Art.  Anus, in Surgical
 Dictionary.  New-York, 1830.
  Heustis, (J. W.)  On Prolapsus Ani.  In Am
Journ. Med.  Sc.  V. 546.  Philad. 1830.  Ibid.
 Case of Prolapsus Recti, successfully treated by
an Excision.   In same Journal.  XI. 411. (1833.)
  MACrARLANE, John.)  Clinical Reports of the
 Surgical Practice of tlie Glasgow Royal Infirm-
 ary,  p. 151.  Glasgow, 1832.
   See also the General Treatises of Howship,
 Calvert, Mayo, &c., and the General Treatises
 on Surgery.

   J 6. Inflammations of the anus.  Both
 the interior of the anus, and the parts about
 its  margin, are  subject to inflammation
 from various causes.  When deeply seated,
 these inflammations terminate almost in-
 variably in abscess, and we therefore refer
 the reader to section 13. for further inform-
 ation  upon their  history  and treatment;
 confining ourselves, at present to the con-
 sideration of such only as  have their ori-
 gin, and, in a great degree, their seat also,
 in the tegumentary membranes.
   The margin of the anus, and the sur-
 rounding parts, are very frequently affect-
 ed with irritation or excoriation, sometimes
 from the unavoidable attrition of the parts
 in walking or riding long distances, some-
 times from gross  want  of cleanliness, or
 from an  entanglement of the hairs with
 which the parts are clothed, and sometimes
 from the removal of the hair, by the patient
 or the surgeon. Of irritation from the two
 former causes it is scarcely necessary to
 speak; but of that produced by shaving or
 cutting  the hair, we may add one  remark
 with propriety. The skin around the anus
 is endowed with exquisite sensibility, and
 cannot endure long-continued motion, even
 upon  itself,  without unpleasant   conse-
 quences.  The hair  is  intended in this,
 as in many  other situations, to prevent
 the  contact of the sides of the nates, and
 to act like a friction-wheel in machinery,
 to diminish the attrition.  For this reason,
 it is much more abundant in the male sex,
 because the anus is much more  deeply
 situated in man.  To remove it entirely
 would, therefore, produce no slight incon-
 venience ; but when cut short,  or when,
 after being shaved, it  has again  grown to
 a certain length, it acts like a harsh brush
 upon the delicate  skin, and may produce
 very severe inflammation.  M.  Velpeau
 states the case  of a  physician  who re-
 moved the  hair  with  scissors, and  in
 whom such violent pain and fever followed,
 that he was compelled to keep his bed for
 three days.  The hair should be removed
 by the surgeon, therefore, only when there
 is strong occasion  for such a proceeding;
 and the nates ought then to be kept com-
 pletely separated by some mild application,
 until the hair has regained sufficient length
 and  pliancy.  The most soothing applica-
tions to this  kind of  irritation,  are cold
water or cold lead-water, when  the cuti-
cle preserves its integrity, and simple ce- 
ANUS. (Inflammations.)
107
 rate  or  Goulard's  cerate,  spread upon
 patent lint when there is excoriation.
   There is a more chronic form of irrita-
 tion in the same part which I have never
 seen distinctly noticed by writers, although
 in some cases it is a very troublesome and
 disgusting complaint  It results frequently
 from  culpable want of cleanliness, but  it
 may occur from other less obvious causes.
 The  frequent  discharge of  stimulating
 matters from the rectum, particularly in
 good livers and the intemperate, act upon
 the surrounding surface, so as to increase
 very greatly, and also to vitiate, the natu-
 ral and peculiar secretion with which it  is
 lubricated. The parts are kept continually
 moistened, and being almost  in  contact
 and protected from exposure, the follicles
 of the skin  enlarge, the cuticle  becomes
 thinner, and the  surface takes on some-
 thing of the mucous character.   This is
 much increased by the  external applica-
 tion of mechanical or chemical  irritants,
 and at length  the patient is sometimes
 driven by the great inconvenience it occa-
 sions,  to consult his surgeon.   Not unfre-
 quently the  latter seeks in vain  for  the
 source of the flow within the anus, when
 its true seat  is entirely external, and may
 extend over nearly the whole surface of
 the  perineum,  particularly in corpulent
 people.   This  complaint will generally
 yield  to habits of perfect cleanliness and
 moderation in diet aided  by daily ablution
 with cold water, the avoidance of rough
 or stimulating applications, and, above all,
 the use of dry lint or  linen, applied so as
 to absorb all moisture, and prevent attri-
 tion from the clothing.
   The integuments of the interior of the
 anus are  liable to similar irritations from
 the passage of hardened faeces, or from the
 vitiated secretions discharged in diarrhoea,
 dysentery, &c.  They are somewhat more
 grave  in  character than  those which  are
 external,  being  generally attended with
 some fever,  or  glairy, yellow, flocculent
 discharges, sometimes streaked with blood,
 tenesmus,  constant desire to go  to stool,
 much smarting or burning pain, and a sense
 of weight, or of the presence of some
 foreign body in the anus.   While inflam-
 mation of this character continues simple,
 that is, when it is not complicated with
 any previous or consequent organic lesion,
 it  is a slight affection, and easily managed.
 When the fever is considerable, venesec-
 tion  may  be  advisable.   The  diet  should
 be rigorous, and  it may be proper, in some
cases, to check the movement of the bowels
by  an opiate.   Emollient  clysters, and
 bathing, or the semicupium, are generally
 productive of relief in a short time. (Vel-
 peau, Diet,  de Medecine, III. 281.)
   Erysipelatous inflammation of the anus
 is often a very severe and fatal affection.
 The graver forms of this complaint, those
 which terminate  in suppuration or  gan-
 grene, are generally treated of, by authors,
 under the head of abscess of the anus;
 but as they have much less connexion
 with abscess, properly so called, than  with
 cutaneous inflammation, we prefer noticing
 them here.
   All the forms and complications of ery-
 sipelas may affect  the vicinity of the anus.
 The inflammation  is often purely local, and
 occasioned by local irritations to the skin,
 such as the  application of certain stimu-
 lating plants, adhesive  strips,  unguents
 containing turpentine, &c. In other cases,
 erratic erysipelas, while traversing other
 parts of  the  body,  invades  the  anus
 also.  Sometimes  the disease is confined
 entirely to the skin; at others, it is com-
 plicated with diffuse inflammation of the
 cellular tissue, producing the varieties for-
 merly termed erysipelas phlegmonoides,
 and erysipelas cedematodes.
   The inconveniences and dangers attend-
 ant upon this complaint when situated as
 described, result chiefly from the extensive
 associated  actions  or sympathies  of the
 part, and  from the peculiar structure an I
 abundance of the  cellular tissue of the
 region.   In all  cases, the constitutional
 symptoms are much more severe than the
 mere extent and gravity of the inflamma-
 tion would lead us to expect:  still, there
 is nothing absolutely peculiar in the nature
 or consequences of the disease when  thus
 located; and the reader is therefore refer-
 red to the article on Erysipelas, and  that
 on Cellular Inflammation, for  all discus-
 sions of the general principles of treatment.
 Our remarks will be confined, in this place,
 to a few specialities.
   When  the inflammation is  simple, or
 confined entirely to the skin, as is  gene-
 rally the case where there exists no epi-
 demic tendency to erysipelas and its con-
 geners, and when the patient's constitution
 has not  been undermined; the  fever may
 run high, the redness and swelling of the
 part may be  considerable, the colour tole-
 rably bright  and the burning pain severe,
 from  the  first.   Such cases,  if treated
 promptly,  are seldom dangerous, and do
 not strongly tend to suppuration. Although
 general bleeding is by no means so exten-
 sively employed in erysipelatous, as in
 phlegmonous inflammations, yet in  cases
 where there  are no strong symptoms of
collapse, it is often advisable;  and, from 
108                         ANUS.  (Inflammations.)
 the extensive sympathies of the part affect-
 ed,  it may  be  strongly indicated  in  the
 sporadic form of the disease  in question.
 Local bleeding, by means of leeches, is of
 more doubtful propriety, as the irritation
 produced by the bites of these animals
 not unfrequently produces erysipelatous
 inflammation.  As this is seldom the case,
 however, when there exists no epidemic
 tendency to diffuse  inflammation  of  the
 cellular tissue, the employment of leeches
 may not be always contra-indicated in se-
 vere sporadic cases.  The local applications
 which give the greatest relief to the burn-
 ing pain and the irritative fever, are  the
 strong aqueous solution of opium, and  the
 solution of acetate of lead; the former acts
 most agreeably in the generality of cases,
 but m some few patients,  all  applications
 of opium to the skin, in erysipelas, prove
 highly  irritating.   The  use of mercurial
 ointment and other unguents,  so strongly
 recommended by some,  has disappointed
 us even in other forms of the disease;  but
 when the  neighbourhood of the anus, or
 any other place where the skin approaches
 towards  the character of mucous  mem-
 brane, is attacked, we  have  sometimes
 found such remedies productive of pecu-
 liarly unpleasant effects, either by increas-
 ing  the local pain,  or by  inducing unex-
 pected  salivation.   Blisters,  so strongly
 recommended by Dr. Physick, in erysipe-
 las of other parts, have seldom been em-
 ployed in this situation;  but there  exists
 no strong  objection to their  use,  when
 they seem to be indicated.
   The inflammation, in cases of this char-
 acter, affects the  middle, as well as the
 lower portion of the anal canal, being  co-
 extensive with the cutis proper, and  hence
 discharges are  productive  of  much pain
 and  inconvenience.   When the diseased
 action extends to the cellular tissue, taking
 the form of the diffused cellular inflamma-
 tion of Duncan (Edinb. Medico-Chirurg.
 Trans.  I. 470.), the symptoms are  much
 more severe, the treatment more difficult,
 and  the termination too  frequently fatal.
 Persons who indulge to excess in eating
 or drinking  are  most obnoxious to this
 affection.  It may occur at any time, but
 the  liability to  it is  greatly increased
 when an epidemic tendency to erysipelas
 and  its  congeners is prevalent.  In this
 form of the complaint the affection of the
skin becomes a  matter of secondary im-
 portance, the danger of extensive suppu-
 ration and gangrene of the cellular  tissue
 and  fascise being infinitely more terrible.
 Indeed, this is by no means a local disease
of the anus, or even of the integuments in
general.  In whatever manner and  situa-
 tion the irritation which proves its exciting
 cause may act; whether it be in a fractured
 limb; in a punctured wound; from the ap-
 plication of a poisonous substance, stimu-
 lating dressings, or vitiated secretions; the
 collapse, in the graver cases, and the irri-
 tative fever, in those which are less severe,
 are much more strongly marked than the
 local mischief in the first stage would
 lead us to expect; and it  is very certain
 that the condition of the hepatic functions
 is much disturbed after the access, if, in-
 deed, the liability to this species of inflam-
 mation does not result, primarily, from the
 effect of intemperance,  or the  epidemic
 cause, upon the hepatic organs. The local
 treatment of the disease  is, therefore, not
 more important  than the  general  treat-
 ment.
   When it occurs in the  neighbourhood
 of  the  anus, diffuse  inflammation of  the
 cellular tissue  generally results  from  the
 irritation of vitiated discharges, or from
 slight injuries produced by the passage of
 hardened faeces; strangulation of a hemor-
 rhoidal tumour has been known to produce
 it;  and, indeed, any injury to a vein would
 be  very likely to prove an exciting cause,
 as  the common operation of venesection
 so often occasions  it in the arm, and as the
 disease is frequently  complicated with, or
 mistaken for phlebitis. (See Duncan, loc.
 cit.  and Earle, Clinical Lecture on Cel-
 lular Inflammation—London Med. and
 Phys. Journ. Jan. 1827.)
  The attack is often marked by nausea,
 slight chilliness, and the other marks of
 the  cold stage  of fever.  A swelling is
 then perceived around the margin of the
 anus, and the skin is more or less changed
 in hue,—sometimes it is yellow, at others
 red, dusky or purple; but the appearance
 of the skin is no certain index of the se-
 verity or extent of the affection.  The tu-
 mour lacks the hardness of a phlegmonous
 mflammation; and, although  the outline
 of the disease may be  clearly defined upon
 the skin, the swelling beneath cannot be
 precisely traced.   The pulse is generally
frequent hard, contracted, and jarring, at
 first; but  it soon becomes weak,  low,
 fluttering, or  irregular;  there is  great
 restlessness, anxiety, often nervous agita-
tion, and the patient complains of great
pain and uneasiness, although the part is
not generally very tender  to  the touch.
 The secretions are, for the most part, viti-
ated or arrested, and the bowels are  com-
monly bound. The swelling extends itself
with great rapidity on every side, toward
the  nates, the back,  and the  perineum;
but it soon loses its firmness, and assumes
more or less of that peculiar doughy or 
ANUS. (Inflammations.)
109
boggy feel which characterizes the diffuse
cellular inflammation in other places. The
disease advances with alarming speed, and
unless very promptly  treated,  it ends  in
gangrene of the cellular tissue, to an ex-
tent that cannot be foreseen.
   On the first attack of this  complaint,
when the colour of the skin is not very
dark, and while the pulse retains its  in-
creased action, venesection may be proper
in some cases; but when the  depression
of the system is considerable, it is obviously
improper. Local bleeding by leeches would
doubtless prove serviceable in the forming
stage, were it not that the  bites of these
animals are particularly prone to produce
or increase erysipelatous disease; and it is,
therefore, advisable to be cautious in their
employment when the epidemic tendency,
already mentioned is prevalent.
   Percival Pott, who  dwells particu-
larly on this affection, directs  early and
free openings to be made in cases of this
character, without waiting for obvious de-
posits of pus. (Chirurgical  Works, Law-
rence's ed. III. 91.)  The plan  of free in-
cisions in the treatment of diffuse cellular
inflammations, generally introduced by Mr.
Copeland Hutchinson, and strongly ad-
vocated by  several eminent British sur-
geons, is more decidedly  applicable  in
those cases that affect the neighbourhood
of the  anus,  than in any  others.  The
plan has been discountenanced on this side
of the Atlantic, in consequence of its ap-
parent severity; how justly, in other cases,
we shall not now pause to  consider; but
in those of the anus, the dangers are so
imminent, that severity can hardly be al-
leged as an argument against  a remedy,
otherwise advisable. It should be remem-
bered, that if we wait for the formation of
matter, we wait also for the occurrence of
sloughs, which are generally extensive in
proportion to the looseness of the cellular
texture  of the part.   The  testimony  of
Mr. Earle goes to show, that  when the
incisions are made before any pus is form-
ed, and when the hemorrhage is promoted
by warm  fomentations, the inflammation
is greatly diminished,  and the case may
terminate favourably in a few hours. (Loc.
cit.)   A mild poultice should be  placed on
the part, after the incisions are completed.
  With regard to the general  treatment
of diffuse cellular inflammations, there are
wide differences of opinion; and, as Dun-
can acknowledges, the practice  is still un-
settled.  The older authorities, like Pott,
advocated a highly stimulating treatment,
as in other gangrenous cases.  Duncan
decides in general in favour of a mild de-
  vol. ii.          10
 pletory course.   Mr. Earle directs that
 immediately after the incisions are dressed
 with the poultice, the patient should take
 a large dose  of calomel and  antimony;
 and, after some hours,  a  free  purge of
 senna and salts.  Whatever may be thought
 of these last-mentioned directions in ordi-
 nary cases, they are obviously inapplicable
 where the disease attacks the anus.   We
 are  informed that in the practice of the
 Pennsylvania Hospital at present the gen-
 eral treatment in most cases of diffuse in-
 flammation  from wounds and fractures, is
 confined mainly to supporting the patient
 by a mild but nutritive diet and to the use
 of diffusible stimuli  in cases of great de-
 pression ; and the results of numerous cases
 show a  remarkable degree of success.  We
 have reaped great advantage, in many in-
 stances, from the employment of small
 doses of calomel, as laxatives, repeated
 every day,  or every other  day, so as  to
 promote a healthy action of the liver; and
 whenever we have resorted to more pow-
 erful purgatives, the effect  has been, we
 think, injurious.  There  is nothing in this
 course  calculated to do  injury, when the
 seat of the disease is in the neighbourhood
 of the  anus; and we have, accordingly,
 employed it in two cases which have come
 under our observation.
   When the colour of the  skin is dusky
 or purplish-red;  when it has a doughy, un-
 resisting feel, and  but  little sensibility;
 when the pulse  is unequal  or  faltering,
 and  there are irregular chills and shiver-
 ing, great debility and mental depression,
 or stupor; the case, says Mr. Pott, is gen-
 erally fatal.   Evacuations, in such cases,
 are out of the question:  and it is remark-
 able, that this very  eminent practitioner
 here declares that " large and deep  inci-
 sions should be  made into the diseased
 parts."  (Op. cit. p. 92.)
   Sir  Astley Cooper  observes in  his
 clinical lectures, that immense  losses of
 substance from gangrene of the anus, often
 recover with  very little difficulty;  and
 there are several astonishing instances of
 this kind on record. Three cases of entire
 destruction  of the soft parts around  the
 anus have occurred within a few months
 at the Pennsylvania Hospital.  In one, a
 female,  the disease involved the labia pu-
 dendi,  and terminated fatally: the others
 were male patients, and recovered.  The
 cicatrices produced  much  deformity by
 their contraction, which distorted the scro-
 tum  and perineum,  but  did  not materi-
ally embarrass the functions of the anus.
The much-vaunted kreosote was employed
in one of these cases, with some advantage; 
110                         ANUS.  (Blenorrhagia.)
 but its principal effect was the destruction
 of the fetor of the diseased or destroyed
 parts. (Am. Journ. Med. Sc.  XV. 355.)
   When this species  of inflammation  is
 extended to the nates, where the cellular
 tissue becomes more fibrous, and is loaded
 with adipose matter, an imperfect attempt
 is often made to limit the extension of the
 disease; one or more  ill-defined tumours
 are formed, and present an appearance re-
 sembling in some degree an anthrax.
   Diffuse inflammation of the  cellular tis-
 sue about the anus, ending in sloughs,  is
 readily distinguished from those cases of
 gangrene  in the same parts  caused by
 tearing the rectum or injury of the urinary
 organs, followed by the infiltration of urine
 or irritating faecal matter.
  Bibliography.—Pott, (Percival.)   Chirur-
 gical Works.  London, 1771.  Edit, by Law-
 rence. 3 vols. 8vo. III. 91.  London, 1790.
  Griffith, (Richd.)  A singular case of repro-
 duction of the sphincter ani, and three other cases
 of the cure  of mortification, &c.   London, 1792.
 pp. 33. 8vo.
  Brown, (Wm.) • Observations  on bloodletting
 from the hemorrhoidal veins in certain cases.
 Edinburgh Med. and Surg. Journal. XIV. 136.
 (1818.)
  Barns, (John.)  A case of gangrenous suppu-
 ration of the anus. Philada. Journ. of Med. and
 Phys. Sciences. II. 168.  (1821.)
  Cooper, (Sir A.) A passing remark  on gan-
 grene oftlte anus, in a clinical lecture.   London
 Lancet. I. 246.  (1824.)
  Lawrence, (W.)   Erysipelas of the trunk,
 caused by an operation on the anus. A case. Lon-
 don Med. Chirurg. Trans. XIV. 113.  (1828.)
  Velpeau.  Art. Anus, in Diet, de Med. edit
 2.   Paris, 1833.
   *! 7. Blenorrhagia of the  Anus.  We
 have spoken, in the previous  section, of
 increased and vitiated secretions produced
 by habitual irritation of the lower portions
 of the anal canal.   Inflammations of all
 parts of the anus may produce correspond-
 ing  discharges of a mucous or ichorous
 character,  and sometimes genuine pus is
 plentifully evacuated while  there  exists
 no  abrasion of the surface, and no ulcer,
 or other breach of continuity.
  A discharge  of  either kind from the
 anus itself may be distinguished from the
 same species of evacuation  from disease
 in other parts of the alimentary tube, by
 the unmixed character of the pus, its more
 uniform flow, the great sensibility  of the
 part, and in general, by the colour and ob-
vious inflammatory swelling  of the inte-
guments within and around the orifice.
  Even when the discharge  is purulent,
and when there is no breach  of the inte-
guments of the part to account for its ap-
 pearance, it will not do to attribute  it in-
 variably to a specific cause; we have seen
 at least one strongly marked case, in which
 the correctness of the habits of the patient
 was  beyond  question.  Yet  in a  large
 majority of instances,  blenorrhagia of the
 anus is doubtless the result of a direct con-
 tact with urethral gonorrhceal matter. The
 amount  of  the discharge  is  sometimes
 very great, and the irritation so high as to
 produce  even violent fever, during  the
 early stage.  It is  well known that gonor-
 rhoea occasionally  becomes extended over
 the glans penis  and the prepuce, and M.
 Velpeau remarks that he has seen  the
 discharge,  in that form  of the disease
 of which we are speaking, not only about
 the margin  of the anus, but over the sur-
 face of the  perineum, between the  scro-
 tum and  thighs,  and even toward the coc-
 cyx. (Diet, de Med. edit. 2.  HI. 285.)
   The treatment  of blenorrhagia of the
 anus should be conducted upon the  same
 general  principles which  govern  us in
 that of the  urethra;  but the  effect of
 injections is  less  likely to prove  dan-
 gerous here, because the parts interested
 are not  so  liable  to  organic  stricture,
 nor is  there  so  much  danger of swelled
 testicle when the flow  is  suddenly  ar-
 rested.    The  febrile symptoms running
 much higher when the disease attacks the
 anus than when it is confined to the ure-
 thra, it is often necessary to carry vene-
 section and  the  antiphlogistic  treatment
 much farther—having due regard, hew-
 ever, to the temperament and general con-
 dition of  the patient.  When these means
 are  properly employed, and aided, if ne-
 cessary, by opiates to obviate the terrible
 pain of the  alvine  evacuations, or the
 spasm of the sphincters, with which the
 case  is sometimes complicated, we  may
 occasionally succeed in arresting the dis-
 ease, very early in  its course, without any
 farther  measures.  In the case of a young
 gentleman in whom an accidental contact
 of pus from the urethra, produced the most
 violent symptoms, such as even threatened
 life, the sphincter  internus  was affected
 with frequent and  long-continued spasms
 for several days, an internal hemorrhoidal
 tumour  became engaged in the stricture
 and  lost  its  vitality.  The discharge  in
 this case  was  prodigious,  but after  four
 free bleedings,   and the  application of
 cool poultices, the inflammatory  symp-
 toms completely subsided.   Under  this
 treatment, aided by forty  drops of the
 acetic tincture of opium, given as occa-
 sion required, the violence of the spasms
was also  controlled; and after  the sepa-
ration of the slough,  no  farther incon-
venience  was experienced,  except  from 
ANUS. (Stricture.)
Ill
the urethral discharge, which soon after
 fielded to injections of sulphate of copper.
 n a  milder case we  reaped considerable
advantage from the employment of injec-
tions  of the mucilage of the pith of sassa-
fras during the height of the inflamma-
tion, this being at once the most soothing,
the most evenly diffusible,  and the most
elegant of this class of preparations.
  When the discharge continues after the
violent symptoms have subsided, recourse
is had to injections similar  to those used
for the urethra.  M. Velpeau makes the
following  practical remarks: "A mix-
ture  of Howard's calomel (cal. a  la va-
peur) and the decoction of marsh mallows,
in  the proportion of 3i. of the former to
gi. of the latter, injected into the anus by
means of a small syringe,  proves  gene-
rally successful.  The same substance, or
the white precipitate, made into an oint-
ment in the proportion of 3 i. to Ji- of unc-
tion,  is equally efficacious. These two ap-
plications appear to me decidedly superior
in effect to the solutions of sulphates of
zinc,  alumine, iron, or copper, and even to
that  of the deuto-chloride of mercury,
when semicupia,  emollient medications,
and the ordinary  means  of cleanliness
have  failed.  Fomentations are always in-
dispensable adjuvants, and it is necessary
to prevent the contact of the parts by the
application  of lint or rags  frequently re-
placed, in the diseased excavations," (i. e.
in  the fossa about the perineum and be-
tween the folds of the skin). (Loc. Cit.)
  This form of disease of the anus is rare
in America,   In  the  few cases subjected
to our observation, in which the complaint
has not yielded to cleanliness and the de-
pletory treatment we have succeeded by
using the solution  of sulphate of copper
added to  the mucilaginous injection, at
first  in the proportion  of a grain to the
ounce, and the strength gradually increas-
ed imtil the discharge was arrested. Com-
presses imbued with  the same  solution
should be applied externally as extensively
as circumstances require.
  § 8. Organic  Stricture  of the  Anus.
Whatever tends to excite inflammation of
the lining membrane  of the anus or rec-
tum may produce organic stricture; but
we shall confine  our observations in this
place chiefly to those cases in which the
disease commences in the anus, referring
the reader to the  article on the pathology
of the rectum for information on the va-
rious  forms of the complaint in which the
latter part becomes affected consecutively;
as in  carcinoma, invaginations, and ha-
bitual  torpor of the great intestines.  As
many of the acknowledged causes of stric-
tures of the anus;  such as  inflammation
induced by dysenteric discharges, or cho-
lera; syphilitic complaints,  primary  or
secondary; obstinate constipation, and the
consequent  passage of hardened  fieces;
&c.—are  even more frequently produc-
tive  of  coarctations higher up in the ca-
nal ; and  as the  rational signs  of these
several  kinds  of  stricture rarely furnish
sufficiently strong diagnostic marks, with-
out the  aid of examinations per anum, we
must refer to  the article just mentioned
for these signs also—contenting ourselves
at present with a view of the causes and
treatment of the  local symptoms obvious
to the senses.
   One of the most common forms of stric-
ture  of the  anus, is situated near the up-
per margin of the internal sphincter, and
results from plastic  inflammation of that
part.  Mr. Charles Bell gives the fol-
lowing  description  of  the  mode  of  its
formation.  " The third kind of stricture
of the anus is  the true stricture, what is
meant by common  scirrhus, ascertained
first  by  feeling of it and then by the ex-
act place  of it  Have  you  never asked
yourselves why it is that stricture of the
rectum is so exactly situated, so that when
you introduce  the finger to examine the
part you find that the finger passes up to
the second joint,  before you can feel the
contraction 1  You have the answer in the
anatomy of the part; the stricture takes
place at the margin of the internal sphinc-
ter ani muscle, which is often occasioned
in this  way:  by  habitual constipation a
great straining sometimes takes place, but
the intestines  become sluggish, refuse to
act;  and if the intestines do not act nei-
ther will the sphincter give way,  for the
sphincter  and  the  muscles  of the intes-
tines are  always  alternating in their ac-
tion ; when the one acts the other yields,
so that the person  straining at stool pro-
pels  the feculent matter toward the anus,
and a fold of the  inner membrane of the
rectum  is pushed down directly opposite
the internal sphincter, and this continuing
for a time, a fold  of the  intestine  falls
across the canal at that part, and you feel
it there."  (Clinical  Lecture. Lancet, No.
105.)  This fold 6poken of  by Mr. Bell,
becomes indurated  by the interstitial de-
posit of coagulable lymph, and  it may also
form  adhesions by  an  exudation  of the
same substance upon its surface.
   This form of stricture resembles that  of
the urethra, and requires the same mode
of local treatment. It is one of those cases
in which  the  happiest  results  may  be 
112                           ANUS.  (Stricture.)
expected from  the judicious employment
of the bougie.  But  it would be very un-
wise  to attempt the cure of the stricture
without the removal of the causes which
first produced it; these may be, either de-
ficient action of the bowels from improper
diet or nervous debility (see Constipation),
—stricture, or  invagination, and the con-
sequent accumulation of faeces higher up
in the canal (see Rectum, Colon),—dis-
ease of the uterine, or urinary apparatus
(see Prostate Gland, Uterus), or that hy-
peraction  of  the sphincter mentioned  by
Delpech, Boyer, and others, of which we
have spoken in the section on spasm of the
anus.  (q. v.)  While speaking of this form
of stricture,  it may be  well  to mention
that it is sometimes complicated with false
membranes thrown out upon the surface,
so as  to form partial  septa or fillets across
the canal, such as are noticed by Ruish,
Moroaoni, Boyer, Copeland, &c.  (See
Rectum.)   When these occur in  or near
the anus, they are easily destroyed by the
bougie; and, as they are very extensible
in their nature, they may  not afterwards
limit  the motions of  the part  The great
evil they  produce,  so  long as any traces
of them remain, is their constant liability
to renew the adhesions.  Blood generally
follows  their rupture,  which  proves that
they have  become organized.
   In  many cases of contracted anus, says
Calvert,  there  is  merely a thickening
and consolidation of the fine skin of this
part  and  of the adjacent  cellular mem-
brane, without any disposition to spasm or
to  specific structural  disease.  This,  at
first  does not occasion much inconve-
nience, except during  a dry and consti-
pated state  of the  bowels, when  some
degree of pain and difficulty is felt  in pass-
ing a hardened motion,  more, perhaps, in
consequence of the parts about the orifice
of the gut not being as susceptible of dila-
tation as  usual,  than  from  any absolute
contraction.  If  the complaint continue
for some time,  it is  usually followed by a
slight degree of prolapsus ani, the neces-
sary consequence of straining at stool, by
which the inner membrane is gorged with
blood, and being elongated, is forced down,
whilst the fibres of the sphincter muscles
being continually exerted,  as if some for-
eign  body were accidentally lodged in the
same part by degrees  become morbidly
contracted, and add very considerably to
the straightness of the passage. (Practical
 Treatise  on Hemorrhoids, &c. p.  204.)
This  form of stricture may result from any
cause of chronic irritation, and  is not un-
frequently observed  in persons who have
been long subject to hemorrhoidal disease.
It generally gives rise to but little incon-
venience, if proper attention is paid, in thq
early stage, to the habitual condition of the
bowels, and to the diet of the patient.  If
neglected, however, it may at length be-
come a cause of great evils; for the elas-
ticity of  the skin is sometimes so  com-
pletely lost, that crevices  are formed by
the distension of the canal, giving rise to
great pain and refractory ulcerations, and
it may become necessary to resort to se-
vere  surgical measures for their  relief.
(See J 10.)  In  some cases the  sphincter
externus, constantly irritated by  these cre-
vices or sores, becomes permanently con-
tracted by a deposition  of lymph within
its substance, destroying in great degree
its functions; a complete  division of this
muscle then becomes necessary.
   There  is a form of stricture mentioned
by Mr. Charles Bell (loc. cit.), in which
the deposit of lymph takes place chiefly
around the margin of the anus,  causing a
contraction of the integuments like that
which  we sometimes see in the mouth,
and which there proves so exceedingly in-
tractable.  This stricture is sometimes so
great as to prevent any body larger than a
goose-quill from being introduced.  For the
relief of this most unhappy state of things,
the knife is indispensable. Mr. Bell recom-
mends  that in this  case, a piece of thin
cloth should be spread over the anus, its
centre carried up into the rectum upon the
point of a probe, and the sac thus formed
gradually filled with  lint  until  the lower
part of the rectum  is distended.   Then,
using the neck of the sac of cloth as a
handle, he directs it to be drawn  down
so as  to  make the anus very prominent.
A circular piece, including the stricture,
is then to be  removed  by a single sweep
of the knife, cutting  upon the sac.  This
operation is essentially the same with that
of White for obstinate prolapsus ani, and
is liable to the same objections.  (See $ 5.)
Nor can we perceive the necessity of the
proceeding;  for,  in  the worst cases of
stricture of the  mouth, we do not pretend
to excise  the whole mass of the diseased
structure. This variety of the disease must
be very rare: we have  never seen it, but
should  certainly feel better  disposed to
trust for success to the deep lateral  inci-
sions recommended  by  Delpech  in the
worst forms  of  stricture from  primary or
secondary syphilis, and  even in the still
more unhappy cases  of great contraction
from cicatrices.   If, in any form of stric-
ture not connected with a disease neces-
sarily fatal, all  other means, such as the 
ANUS. (Stricture.)                           113
regulation of food and laxatives, the cau-
tious use of bougies, the lateral incisions,
&c, should have failed, and if we have no
other prospect than death by obstruction,
or a severe-operation with a probability of
consequent weakness of the most disgust-
ing kind, we might be induced, indeed, to
consider the propriety  of converting the
natural anus  into an artificial one,—for
there is ample evidence to show that life
is not  sacrificed by the excision  of the
lower part  of the rectum  (see Rectum),
and Nature has even been known to resort
to an analogous process for her relief in
complete stricture, choosing the location
with even  less judgment.  But in  such
circumstances, we should not  be content
with  the  excision  of  the integuments
alone, unless, indeed, the stricture be con-
fined absolutely to the  proper skin of the
lowest portion of the anal canal;  for,  in
this case, it would scarcely differ from a
simple excrescence of the part, and might
be  treated  by excision without danger.
The result of the cases of diffuse inflam-
mation of the  cellular  tissue around the
anus, and external to the sphincters, proves
that the contraction of circular cicatrices
in this situation, does  not  very seriously
embarrass the functions of the canal.  (See

   In  olden  time, when the integuments
and other indurated parts were freely re-
moved in all  cases of abscess and fistula
about the anus, from mistaken  pathologi-
cal opinions, it was much  more common
than  at present to see strictures of this
canal  from  the contraction of cicatrices:
we have quoted a case in point from Ches-
elden, when speaking of prolapsus ani,—
but as we have seen in the last paragraph
that some surgeons still treat the destruc-
tion of integuments in this neighbourhood
with  less caution than we  should  feel, it
may be proper to add a few remarks of the
justly celebrated professor of Montpellier
on this subject  " In fine," says Delpech,
" it happens, that in cases of habitual en-
gorgement  and  eversion of the internal
membrane of the anus, in consequence of
the presence of hemorrhoids, in attempting
the excision of the scroll (i. e.  the  lateral
tumours formed by this slight shade of pro-
lapsus), which sometimes occasions insup-
portable inconvenience, the surgeon has
extended the operation  to the whole cir-
cumference of the anus.  In these cases,
it has frequently resulted from this prac-
tice, that the circular cicatrix has contract-
ed the natural passage, and rendered  it al-
most incapable of performing its functions.
Experience has  proved that in this  state
                10*
of things, the use of dilating instruments
is rarely serviceable, and is often produc-
tive  of intolerable pain.  But  advantage
has often been derived from making one
or two incisions on the circumference of
the anus, in  such  a  manner as to  divide
perpendicularly the whole thickness of the
cicatrix, and  penetrate  into the subjacent
parts.   It is  then  possible to introduce a
plug of lint;  and the interposition of this
foreign body during the cicatrization of
the incision,  is sufficient to maintain the
free exercise  of the functions of the  anus."
(I. 597.)
  There are  two forms  of stricture  of the
anus resulting from disorganization  of the
lining membrane, and differing in this re-
spect from the simple thickening and cal-
losity produced by the deposition of lymph,
or, to speak  more properly, by adhesions
within  the  skin and  cellular  tissue, as
noticed  in the last  variety.  Both these
forms are attended with considerable irre-
gularities of  surface, at least in their ma-
ture stage; and, in both, the disease extends
to the rectum, or may,  perhaps, originate
in that viscus.  The first of these forms is
considered as syphilitic. It makes  its ap-
proach  very  slowly, and produces  thick-
ening, often  of  a  cartilaginous firmness,
which sometimes surrounds the canal en-
tirely, and, in other cases, forms congeries
of small tubercles, encroaching more or
less  upon  the  canal.   It  is very  rarely
attended by distinct ulcerations. M. Del-
pech considers it as a secondary  conse-
quence of the venereal disease, and states
that  it  yields to the local and general
treatment adapted to that complaint. (Op.
cit. p. 591.)   The other form is produced
by scirrhus of the rectum,  in  which the
anus, generally, but not invariably, becomes
interested consecutively.  Both the diag-
nosis and treatment of these affections are
unsettled and difficult,  and they will be
more properly considered in detail  in the
article  on the rectum.   Obstructions of
the  anus from  hemorrhoidal  and other
tumours, venereal  excrescences, &c., will
be spoken of under the  appropriate  heads.
  We will close this section with these
general remarks: The treatment of all the
varieties of organic stricture of the anus,
requires the most careful  attention to the
diet and habits of the patient; the avoid-
ance or removal of all causes of local  irri-
tation;  the  arrest of  the  inflammatory
symptoms, when present by  appropriate
measures; the cautious use of distending
instruments,  and, as a last resort, the en-
largement of the canal  by incisions.  Of
the use of bougies, it should be remarked, 
114
ANUS.  (Tumours.)
that they should  never be very hard, and
that distension  should be  effected very
gradually. Neglect of this precaution may
even occasion fatal peritonitis. (Vide C.
Bell.  Loc. Cit.)  Incisions produce per-
manent relief in most cases,  but  not so
complete  as to prevent the necessity of
constant attention  to  diet  and regimen,
and this is particularly the case in stric-
ture  from eschars after  a loss  of  sub-
stance. It is too much to expect the parts
in these cases to recover their functions
perfectly.   In the  scirrho-contracted  va-
riety the disease is of  course incurable,
but  even here,  incisions have prolonged
life for a considerable time. (See Rectum.)

  Bibliography.—Copeland.  Observations on
some of the principal diseases of the anus. Sect.
1.   London, 1810.
  Delpech.  Precis Elimentaire des maladies
riputies chirurgicales.  I. 591.  Paris, 1816.
  Howship.  Practical observations on  the  dis-
eases of the lower intestines and anus.  Chap. 1.
London, 1821.
  Calvert.   A practical  treatise on  Hemor-
rhoids or Piles, Strictures, &c. Chap. 3. sect. 1.
London, 1824.
  Charles Bell.   Two clinical lectures on her-
nia and strictures of the rectum and anus.  Lan-
cet 1st series. XII. 545 and 577.  (1827.)
  Salmon.  Practical essay on strictures of the
rectum.  London, 1828.
  Mayo.   Observations on injuries  and diseases
of the rectum.  Chap. 7.  London, 1833.

   § 9. Tumours of the Anus.   The anus
and its vicinity are liable to a great variety
of tumours, vegetations and excrescences,
as  scirrhus, condyloma,  steatoma, varix,
&c, none of which are absolutely peculiar
to  these  parts,  except  the hemorrhoidal
enlargement. (See Hemorrhoids.)  It is un-
necessary here  to  enter into any  details
respecting them; and we shall therefore
confine ourselves to some general remarks
upon the  cautions necessary  in  the  re-
moval of these encumbrances by surgical
operations. The knife and the ligature have
both been resorted to for this purpose,  and
each has its advocates. The objection urged
to  the former is the danger  of hemor-
rhage ; to the latter, the pain it causes.
   The two lower portions of the anal ca-
nal may be inspected  completely without
the  aid of instruments; the blood-vessels
in this part are  inconsiderable, and if di-
vided may be taken up without difficulty.
In  the superior  portion of the  canal  the
vessels become larger, but as the  surface
may still be inspected by the aid of a pro-
per speculum, vessels near the margin of
the internal sphincter may be tied, if  ne-
cessary, with a little dexterity; but those
which lie  deeper,  toward the  superior
margin of the muscle, cannot always be
controlled with certainty, until the sphinc-
ter is divided, so as to admit of great di-
latation.  Again; if secondary hemorrhage
should take place in the middle or in the
lower region of the anus, it would become
immediately obvious externally, and could
be repressed very readily, when occurring
in the latter locality, and without  much
difficulty, in the former; but  when the
same accident happens in the superior re-
gion, the blood sometimes flows back into
the rectum, and accumulates there to a
great extent, so as to exhaust the strength
of the patient before he or the surgeon
becomes aware of the  fact, as was the
case  in  one of  the  operations for  irre-
ducible prolapsus performed by White.
(See  (i 5.)   Hemorrhage of this character
may indeed be  checked  by compresses in
some cases, but it requires considerable
skill to accomplish the purpose, and some-
times it  is absolutely necessary to  relin-
quish it  and arrest the  bleeding  by cau-
tery or by applying a ligature to the ves-
sels.
  There can be little question then, of
the propriety of employing  the knife in
all tumours situated below the margin of
the internal sphincter.  But in many of
those attached altogether above this  spot
the danger  of hemorrhage, and the  infe-
rior sensibility  of this part,  furnish, we
conceive, solid  reasons for preferring the
ligature, provided there  is nothing in the
firmness or condition of the tumours to
interdict its use.
  It is more difficult to decide upon the
best mode of removing tumours having
extensive connexions  both above  and be-
low the margin of the muscle, and conse-
quently covered partly by mucous mem-
brane and partly by external integument
owing to the danger of hemorrhage  if the
knife be used,  and the intolerable  pain
and serious nervous irritation produced by
the ligature from its action on the lower
portion.  Dr. Physick has devised  a pe-
culiar method of operating, which, whilst
it is  secure from  all danger of hemor-
rhage, removes, he thinks, the  grave ob-
jection to  the  employment  of ligatures.
It consists  in   completely  dividing the
skin around the base  of  the  tumour  with
a scalpel, carrying the incision from the
edge of the mucous  membrane  on one
side  to the  same level  on  the other,
giving it such  a direction that when the
whole tumour  is afterwards embraced in
the loup,  the ligature may  traverse the
incision,  so as  to act  when tightened,
upon  the  subcutaneous cellular  tissue
and  the  mucous membrane  without in- 
ANUS. (Tumours and Ulcers.)                      115
eluding any portion of the skin.  When
it is  impossible to embrace the whole tu-
mour in one or more ligatures, there is no
longer  a  choice of measures,  and if any
operation is admissible, the knife  must be
used  without  reference  to  the  location.
When  rapid and  alarming hemorrhage
takes place, the bleeding vessels  must be
tied  or cauterized, and if necessary,  the
sphincters  may be  divided to  facilitate
their discovery.  When  the hemorrhage
occurs  from small vessels even above the
anus, in the lower part of the rectum, it
may  be arrested in many cases by com-
presses introduced into that intestine. The
following mode of  forming  such com-
 presses has been employed by Dr. J. R.
 Barton of Philadelphia. Take a sufficient
number of pledgets, made from  portions of
a common  roller bandage, or other piece
of muslin, about two inches in width, and
long  enough, when loosely wound, to gain
ready admittance into the rectum.  Let
each  pledget be secured by a ligature tied
round the middle of  the roll, and long
enough to leave several inches  of the liga-
ture freely dependent  from the anus.   In-
troduce  these  pledgets,  previously  tho-
roughly oiled, one after another, into the
rectum, until the lower part of that viscus
is distended by the muslin, leaving the
free  ends of the ligatures hanging from
the anus.   This being done,  divide the
projecting ends of the ligatures,  carrying
one  half their number toward the right
hip and the other half toward the left;
then  take a larger pledget or small roller,
firmly wound,  and place it  between the
parted ligatures, with  its  axis  in  the an-
tero-posterior direction; lastly, gather the
ligatures  from  the opposite sides of the
anus, and tie  them across  the  external
pledget with sufficient firmness to arrest
the hemorrhage.  The great objection to
this apparatus  is that its presence in the
rectum  is tolerated with  great difiiculty.
M. Dupuytren  once succeeded in arrest-
ing a hemorrhage of  this kind by intro-
ducing  into the intestine a pig's bladder,
afterwards stuffing it  with lint; but  he
found even this apparatus insecure, be-
cause it was almost always discharged in-
voluntarily by the action it excited in the
rectum  (Lecons Orales. I. 353.); and the
same  objection exists to sponge and other
compresses, though they  prove useful in
some  cases.  This surgeon relies mainly
on the  actual  cautery  in grave  cases,
but his  remarks are  applied  more par-
ticularly to the  consequences  of opera-
tions on some forms of hemorrhoids (q. v.).
Hemorrhages of a less  alarming character
 may be relieved by cold injections, a pro-
 per attention to position, and keeping the
 patient cool.   The whole subject  of he-
 morrhage  from the  anus will be  more
 fully discussed in the article on Hemor-
 rhoids.
   § 10.  Ulcers of the Anus.  Ulcers oc-
 cur in the anus from a great variety of
 causes, such as mechanical injuries from
 the introduction of  instruments, or the
 passage  of hardened  faeces  or  foreign
 bodies taken into the stomach; the contact
 of venereal virus; unnatural crimes; unu-
 sual and too rapid distension; the engage-
 ment of faeces  in the mucous follicles and
 their consequent enlargement; &c.  From
 whatever cause these ulcers may result,
 they not unfrequently produce severe suf-
 fering  and prove   very unmanageable.
 Some  of the principal  difficulties in the
 treatment  are  occasioned by the radiated
 duplicatures of the  skin in the lower part
 of the canal, the excavation of its middle
 portion,  and the disposition to form circu-
 lar folds in the upper division.   These ir-
 regularities often conceal portions  of the
 sore, and make it difficult to apply reme-
 dies to the whole surface; they even give
 a  characteristic form to most of the ulcers
 in the different regions just  mentioned.
 Thus,  below  the  sphincters,  ulcers are
 generally lineal and concealed in the ra-
 diated folds; between the sphincters, they
 sometimes exhibit the same form, particu-
 larly when they result  from  distension;
 but more generally, they spread and in-
 volve  a considerable  portion of the  sur-
 face of the enlargement noticed in  that
 part of the canal;  above the margin of
 the  internal sphincter, on the  contrary,
 they  commonly extend  most rapidly in
 the circular direction.
   Still graver  embarrassment  is  occa-
 sioned by the  great mobility of the part,
 and the absolute necessity for the frequent
 exercise of its proper functions.  Bearing
 these  facts in mind,  and  recollecting
 the peculiar action of the sphincters in
 restricting the freedom  of circulation in
 the veins of the part, it is easy to under-
 stand how far  the treatment of  ulcers of
 this part must differ from that of similar
 affections of other places. Before proceed-
 ing to  notice the several forms of ulcera-
 tion, it may be proper to remark that they
 all require such a course of diet and occa-
 sional gentle aperients as are calculated
 to diminish the  quantity and the consist-
 ence of the discharges, so as to secure the
most perfect repose of the parts which the
nature of the  case  and the condition of
the patient will permit   When irritation 
116
ANUS. (Ulcers.)
runs high, local bleeding, emollient poul-
tices, and small  mucilaginous injections,
are advisable, provided they do not inter-
fere with the application of other neces-
sary topical remedies.
   a.  Ulceration from mechanical injury.
Under  this head may be included such
abrasions and lacerations as are produced
by over-distension, or by the passage of
hardened faeces,  as well as those which
follow surgical operations, and the care-
less  employment of instruments.
   In  cases of habitual costiveness, the
hardened contents of the rectum occasion
great friction upon the mucous membrane,
particularly near the margin of the inter-
nal sphincter, and this sometimes produces
a transverse laceration  of greater or less
extent   The patient is generally con-
scious of the  accident  at the moment of
its occurrence; a sense of tearing,  and
sometimes an acute  pain in the part  is
superadded upon  the soreness usually felt
on going to stool.' If application is made
to the surgeon immediately, which is un-
fortunately but seldom the case, the cure
may be effected in a very short time, sim-
ply by  the exhibition of repeated warm
injections so as to secure the daily eva-
cuation of the rectum, without straining,
and  by confining the patient to  a fluid
diet.  But when neglected for a few days,
this laceration becomes a confirmed ulcer;
great pain is  experienced, particularly at
the time of a stool; a discharge of mucus,
pus, and occasionally blood,  is established,
and  the ulcerated surface  may be  felt by
the finger introduced into the anus.  The
complaint in most instances, may still be
cured by attention to the  directions just
noticed,  aided by suppositories of opium,
or belladonna, for the relief of the pain.
Sometimes the application of mild mercu-
rial ointment or lunar caustic, pure, or
diluted  with  an  ointment  has  proved
highly serviceable, and  it may be made
without much difficulty by the  aid  of the
speculum.   If inflammation  runs high,
leeches within the  margin may be  em-
ployed.   When the disease proves invete-
rate and there is danger of complete per-
foration of the intestine, or when the con-
stitutional symptoms are alarming, it may
become necessary to divide the sphincters
by the bistoury, in order to remove the re-
peated straining  of the part in the per-
formance of the necessary functions.
  When  the  cutis gives way in  conse-
quence  of too great or too sudden disten-
sion of the lower portions of the canal, the
crevice  takes a longitudinal direction, and
is very frequently concealed in the longi-
tudinal or radiated folds of the part.  The
natural secretions and impurities keep the
opening  continually moistened, and gene-
rally, by irritating matters; so that imme-
diate reunion is effected  with  difficulty,
and when it fails,  the  frequent motions
produced by the passage of faeces lessen
very greatly the chances  of a cure;  the
sore being continually torn open, it some-
times  becomes  excessively irritable and
painful,  like those slight  incisions about
the joints  of the fingers which  often be-
come intractable from a similar cause. In
this condition the case is sometimes com-
plicated  with spasm of the sphincter, and
the patient is said to labour under fissure
of the anus.   (See { 11.)  Unfortunately
the  surgeon  is hardly ever consulted on
the first occurrence  of an  accident appa-
rently so slight that it may escape the no-
tice even of the patient, or it is probable
that few cases would resist the  ordinary
measures for the treatment of slight lace-
rations in  other  parts, the proper regula-
tion of diet,  aperients, and the temporary
repose produced by opiates  when such
remedies are admissible.
  Abrasions, or  other injuries  of a me-
chanical  nature, sometimes produce  ul-
cerations of the middle region of the anus
which extend over a considerable portion
of its surface. The discharges do not find
a perfectly ready egress,  owing to the
constriction of the external sphincter, but
make a lodgment, and become  irritating
in the intervals between the stools.  These
ulcers are treated on general principles in
other respects, but the circumstance just
mentioned, together with the  mechanical
action of the muscle, and the difficulty of
access to  the sore, sometimes  render it
advisable to  make  a free  lateral incision
into the  external sphincter to facilitate
the cure.  We are informed by Dr. Phy-
sick that he has  frequently performed this
operation for  the  cure of obstinate ulcers
between  the  sphincters.

  Bibliography.—Colles.  On diseases of the
anus and  rectum; in  Dublin Hospital Reports.
V. 155. Dublin, 1830.
  Mayo.  On the diseases of the rectum.
  Brodie.  Clinical lecture on ulcer of the  rec-
tum; in Lond. Med. and Sure. Journ. V. 286.
(1834.)

  b. Aphthous ulcerations.  Besides the
excoriations  produced by  irritating  dis-
charges  in dysentery, cholera, and other
visceral diseases, the chapping resembling
that of the lips in winter, various cutane-
ous diseases, &c, all of which  occasion-
ally attack the anus, and give rise to more
or less serious  inconvenience,  we have 
ANUS. (Ulcers.)                            117
noticed a complaint in several cases that
appears to have escaped observation, or to
have  been confounded with other  more
serious lesions.  It is  superficial excoria-
tion or ulceration, similar to that 60 fre-
quently  noticed upon the inside of the
lips, tongue, and other parts of the mouth,
presenting an irregular and dark-red mar-
gin, the centre being covered with ad-
herent coagulated lymph.  When several
exist at the same time, and approach each
other, the intervening cuticle assumes a
dead-white hue, and is  somewhat thick-
ened, as if by the imbibition  of the mois-
ture of the part.  The pain is intense and
burning, and  is very much increased  by
contact with the dry finger, or by the dis-
charge of faeces.  In  the cases that we
have noticed, it has been contemporaneous
with  similar excoriations of the  mouth,
and decided  symptoms of abdominal irri-
tation. It is distinguished from most other
superficial ulcerations  by the absence  of
ichorous discharge; from chancre, by the
want  of the  hard  and elevated or exca-
vated margin, and from the  disorganiza-
tions of the lining membranes of the anus
and rectum from secondary  syphilis and
other very serious diseases, by the absence
of all cartilaginous hardness of the integu-
ments, or  disposition  to tubercular en-
largements.  It seems to be generally, if
not always, limited to such  parts as are
covered by cuticle,  so  that it does not ap-
pear to extend beyond  the margin of the
internal sphincter. In the first case of the
kind which fell under our care, we em-
ployed, in  addition to the necessary con-
stitutional treatment, solutions of the sul-
phates of alumine, zinc, and copper, and
the dilute acids, without any benefit; but
the symptoms were very much relieved
by an ointment of extract of cicuta, which
we have since applied  with equal effect in
two other  cases.  Not having  seen this
complaint in its earliest stage, we cannot
pronounce positively upon the mode of its
commencement;  but  the  similarity be-
tween these excoriations and those of the
mouth already noticed, leaves little doubt
of their identity.  These latter commence
with the  secretion of a  thin layer of lymph
beneath the cuticle, which, if not speedily
reabsorbed, produces exfoliation of the cu-
ticle,  and  extremely painful ulcerations.
This disease resembles aphtha very strong-
ly,  and is probably the same with  the  af-
fection noticed under  that title as  occa-
sionally  occurring  within the  vulva,  as
well as  in the mouth, by many writers,
from Hippocrates to  Van Sweiten, and
also by some modern authors. (See Diet.
de Med.  edit. 1. Art. Apkte.)  We have
seen the  same disease upon the mammary
areola, of females.   In one of the cases,
it  produced very severe  general disturb-
ance ; and as there exists perhaps but little
distinction between this irregular deposit
of lymph and the genuine aphthous pus-
tule, which is known to be attended by ir-
ritations  throughout the alimentary canal,
it is not improbable that we may be in error
in confining the sphere of its influence to
parts  invested  with  cuticle, particularly
as symptoms of abdominal  irritation  are
generally present (See Aphtha.)
  c.  Venereal ulcerations.  These may be
primary,  or secondary, and may take va-
rious forms.  The rhagades  of this  part
are generally  long  narrow  ulcers con-
cealed in the converging folds of the skin,
and are  readily distinguished from other
superficial affections, by the peculiar ichor-
ous discharge, the copper-coloured hue of
the surrounding  parts, and  the  grayish
surface of the  sores themselves.
  Chancres, when they occur in this situa-
tion, usually commence in the middle re-
gion between  the  sphincters,  and  fre-
quently  extend high  into  the rectum;
where, when neglected,  they sometimes
give rise to fistulse, peritonitis,  perfora-
tions of the bladder, or other very serious
disasters.  They are easily recognized by
their excavated or festooned edges, and
the copper colour of the  skin in  their
neighbourhood; the absence  of excessive
sensibility  and  of lancinating pain; and
the freedom  from scirrhosity in the sur-
rounding surface; the hardness, when pre-
sent, being confined to the edges alone.
These marks are quite sufficient to distin-
guish them from carcinomatous' disease,
and from that  form  of scirrhus or tuber-
cular stricture, sometimes attended witb
ulceration, which Delpech considers as a
form of secondary syphilis. (See Rectum.)
These ulcers are said to yield but seldom
to general treatment alone; but the local
measures required are such as are requi-
site in similar ulcers of other parts: they
will be mentioned in the appropriate gene-
ral article.  According  to  M. Velpeau,
deaths result in the French hospitals, from
venereal ulcerations  of the anus and rec-
tum, much more frequently than  is gene-
rally  supposed; but  they  are certainly
very rare on this side of the Atlantic.
   For information on ulcerations  and  de-
generations  of the   tegumentary mem-
branes of the anus connected with scirrhus
and cancer, see the article on  the patho-
logy of the rectum.
   There is yet another familiar disease 
118
ANUS. (Fissure.)
frequently affecting the anus,  and giving
rise to superficial ulcerations—this is the
syphilitic mucous pustule; but as this dis-
ease occurs on  the perineum, the labia
pudendi, the pubis, the mammae, and occa-
sionally on other parts of the body,  we
refer  the  reader, for  information on its
pathology and  treatment  to  the article
Syphilis.
  J 11.  Fissure of the Anus.   This title
has been bestowed by Boyer  upon an as-
semblage of symptoms very rarely observ-
ed by American practitioners.  We have
never met with it, either in public or pri-
vate practice, and  several eminent sur-
geons in Philadelphia declare  that it has
not occurred under their observation. The
English writers  on  the anus  and rectum
use the  term  indeed,  but they sometimes
apply it to other  affections which have
little  in common with  the  disease  de-
scribed by Boyer.  In France, however,
it has attracted much attention; it is said
to be by no means rare at Paris, and it is
necessary that we should notice it in order
to render this article  as complete as pos-
sible.
  This  disease  consists  in an elongated
ulceration of the middle and  lower part
of the anal canal,  sometimes extending
upward onto the mucous membrane above
the internal sphincter, sometimes conceal-
ed between the converging folds of skin
around  the margin,  and generally invisi-
ble until the anus is considerably everted.
This peculiar ulceration is said to be in-
variably attended by spasmodic contrac-
tion of the sphincters and severe  burning
pain; at first  felt only at stool  and  for
some  time afterwards, but gradually  be-
coming more permanent;—which contrac-
tion and pain are considered  as essential
symptoms of the disease.
  No change of structure  is discoverable
by the finger, introduced  into the  anus,
unless in  complicated cases; the  ulcer
being generally so narrow and shallow.
The spasmodic contraction  of  the sphinc-
ters offers, however,  powerful resistance
to the introduction of the finger,  and the
patient  suffers  great pain under all  at-
tempts at dilatation.   The situation of the
fissure may be ascertained  by  pressing in
various  directions round the periphery of
the canal; for  the  moment  pressure  is
made upon the ulcerated line, the  pain is
increased to agony.  If the fissure extends
far downward, it may be perceived exter-
nally by simply separating the converging
folds of  the marginal skin.  In most cases
it can be seen by very careful  inspection,
while the anus is everted. Its appearance
 is that of a very narrow ulcer, marked by
 an increased  redness, but without much
 induration, involving part or the whole of
 the thickness of the mucous membrane.
 The  examination  is  extremely  painful.
 Such is the description of fissure of the
 anus, as  given  by most of the writers by
 whom it  is noticed.  M. Merat asserts
 that the fissure  sometimes extends beyond
 the mucous membrane and  invades the
 muscular envelope of the canal. (Diet, des
 Sciences Medicates.  XV. 544.)   But M.
 Dupuytren avers that it very rarely pene-
 trates the whole thickness of the integu-
 ment. (Lecons  Orales. III. 284.)
   The symptoms at first are not exceed-
 ingly severe.   According  to  Merat, the
 disease is ordinarily announced  by more
 or less considerable pain, on every attempt
 at stool, which becomes excessive and of
 long continuance when the faeces are hard,
 and at first generally subsides in &a hour,
 or less time, after each evacuation.  The
 patients are most comfortable in bed, and
 for  that  reason frequently  avoid rising.
 The  pain  is,  according  to M.  Merat,
 sometimes paroxysmal, which he  attri-
 butes to the pressure of accumulated faeces
 pressing on the sphincter.  At its greatest
 height this complaint  is, says Velpeau,
 accompanied  by horrible suffering.  The
 patients compare the  pain  they feel at
 the moment  of an evacuation,  to  that
 which would  be produced by the passage
 of a red-hot bar. This  sensation of burn-
 ing is sometimes so severe as to produce
 inexpressible  anguish,  with threatenings
 of convulsions,  or  syncope.   Others say
 it seems  as if something was tearing the
 fundament  In the  intervals between the
 stools, there sometimes remain only smart-
 ing or lancinating pains, more or less  se-
 vere,  a sensation  of weight, and some
 griping.   On the approach of defecation,
 on the contrary, the pains become obvi-
 ously augmented.   They do not  acquire
 their greatest violence  until the  moment
 of the expulsion of faeces, and go on de-
" creasing for some hours.
   The constipation becomes  so obstinate,
 that alvine evacuations  take place but
 once in eight, ten, or twelve days, if they
 are  not promoted by art  The patients,
 having an incredible dread of going to
 stool, postpone the moment as long as pos-
 sible,  although they are aware that they
 suffer more by the delay.  The one, two,
 three  or four  injections  necessary to pro-
 cure a stool, sometimes prove still insuffi-
 cient and purgatives given by the mouth
 are  absolutely required to open the bow-
 els.  Some patients think themselves under 
ANUS. (Fissure.)                           119
the necessity of taking  purgatives on al-
ternate  days.   A woman treated  by M.
Boyer resorted to the  use of a canula,
which she fixed in the anus. A patient at
l'H6tel-Dieu insisted that he would prefer
death to the necessity of going again to
stool. Even the fluidity of the discharges
does not prevent the sufferings in all the
subjects, as has been proved by one of the
cases related  by M. Boyer.   Although
some persons are able to walk, sit, or oc-
cupy many hours in employment,  during
the intervals between their attacks, others
are  obliged to remain  in bed, although
they suffer cruelly with  the heat and  fa-
tigue.  In certain cases the lancinating
pains shooting toward the bladder or the
uterus,  according to the sex, extend  even
to the greater part of the hypogastrium.
Digestion is disturbed.    From the  fear of
evacuations the patient  eats but little, and
he loses his natural colour.  His features
soon begin  to  express  the sufferings  he
endures, so that one might believe  that he
laboured under some profound organic le-
sion. Spitting, coughing, or even  sing-
ing ; in short,  all sudden or rather strong
efforts of the lungs, sometimes exacerbate
the pain.   The attempt to introduce into
the  anus,  a  syringe,  tents,  canulae,  or
any other foreign substance, produces the
dread of alvine  evacuations.   The pain
occupies but  a small portion of the cir-
cumference of the canal, and is often ac-
companied  by  pulsations like  those  of
phlegmon. (Diet, de Med. III.)
   The  diagnosis of this complaint  re-
mains unsettled, writers having disagreed
as to the precise application of the term
fissure of the anus.  Some have included
under it not only the linear ulcerations of
the canal attended with spasm  of  the
sphincters,  but  also,   the transverse or
other ulcerations of  the upper  portion
which  have been mentioned  in  the pre-
vious section.  (Mayo.)   Others consider
both the spasm of the sphincters  and  the
linear ulceration, as essential  to  the dis-
ease, and regard them  as standing in  the
relation of cause and  effect; one  party
deeming the  former to be  the primary
symptom, (Boyer, Merat, &c), another,
the latter, (Roche and Sanson, Blandin,
&c.)  A few go still further, and either
speak of the spasmodic constriction as the
true lesion, and the elongated ulcer as a
secondary complication  (Dupuytren) ; or,
on the other hand, they class under  the
same general  head, fissures accompanied
by spasm, rhagades, and simple crevices
or chapping of the cutaneous tissue around
the anus.  (Montegre.)  "These  three
words,"  (Crevasse,  Rhagade, Fissure,)
"have the same signification,"  says  the
author last mentioned.  " They all relate
to a little longitudinal ulceration, of which,
the varieties depend solely upon the cause
which has produced them."
  It seems to be almost universally con-
ceded that a considerable number, accord-
ing to Dupuytren one fourth, of the cases,
are affected with spasm without  ulcera-
tion ;  but it is deemed by most that the ul-
ceration is never found unattended  with
spasm, unless  the term fissure is applied
in the most extensive acceptation, as given
by  Montegre.   The  latter position ap-
pears to us untenable: 1st, because a slight
linear ulcer of the middle  region of the
anus  may very  readily exist  undetected,
if not complicated with spasm or otiier
marked pain; and if detected by the pa-
tient it may still be concealed  from the
surgeon, through motives of delicacy, or
through carelessness with  regard to an
affection so trivial  in  its nature: 2d, be-
cause it is conceded that the spasmodic
symptoms  of fissure  generally  increase
slowly, and do  not  become severe  until
the  ulcer  has  been  irritated  very  fre-
quently and  for  a considerable  length of
time, and it is reasonable to suppose tint
spontaneous cures take place  in many in-
stances before the excessive irritation and
consequent  spasm have rendered such  a
termination impossible: 3d, because in va-
rious operations on the anus, linear ulcera-
tions of the  middle portion of  the canal
are frequently produced, and are readily
healed without the occurrence of spasm:
4th, because in  the ulcerations  caused by
operations, the  cure has been protracted
for a long period,  and the irritability of
the part has given rise to great pain and
 inconvenience  in going  to stool, yet no
spasm has occurred.  We have elsewhere
alluded to an interesting case of this kind
occurring at  the mesial line on the front
of the canal, in a patient of the late Dr.
Wistar, in which  the ulcer was cured
by simply preventing  the  motions of the
thighs upon each other, a plan adopted at
 the  suggestion  of  Dr. Physick  (§ 10.):
 5th,  because  rhagades,  or  linear ulcera-
 tions of the same form occurring in the
 lower  portion of the  canal,  in  venereal
 cases, and which always attract attention,
 from their external location,  are  not un-
 frequently extended into the middle re-
 gion, without producing spasms, as we are
 convinced by actual observation: lastly,
 because the  attempt to explain the fore-
 going facts and to avoid the obvious  con-
 clusion, by asserting  that  there  is  any- 
120                            ANUS. (Fissure.)
thing peculiar or sui generis in that spe-
cies of ulceration which is found so fre-
quently associated  with spasm by conti-
nental surgeons in Europe, is  a petitio
principii, and we  have been  unable to
discover any  facts  in  its support among
the authorities within our reach.
   Having described the various causes
and varieties of spasm of the sphincters,
in the appropriate  section of this article,
it is  unnecessary to adduce further proof
that this affection may originate from other
irritations than those seated in the middle
region of the anal canal.   We cannot
therefore avoid the  conclusion that if the
term  Fissure of the anus be retained as a
nosological distinction, it should be con-
fined strictly to cases  of spasm of one or
both  the sphincters, complicated with  a
linear, irritable ulcer  of the middle re-
gion, which may   be  extended  into the
upper region, or may even originate there
in  cases  affected   with internal  hemor-
rhoids, according to M. Dupuytren.  We
are equally compelled to consider the order
of the symptoms to be accidental.   As  it
is very evident that the causes of the ul-
ceration are  generally  mechanical,  and
that it may occur from the friction of the
faeces, when there  is pre-existent spasm;
or from simple distension, when there  is
not—and as it is equally certain  that the
spasm may arise directly, from the irrita-
tion  of the  crevice,  or more remotely,
from  disease of other  parts, peculiarities
of temperament or even congenital hy-
pertrophy of the muscles, it follows that
either may induce  the other,  or  the two
accidents may be associated without being
mutually dependent.
   These remarks  being premised, it  is
evident that the diagnosis can seldom be
rendered  certain by  the  rational signs
alone, unless  where the disease has ex-
isted  for a considerable time and  remains
free from complication with other inflam-
matory affections   of  the canal.  Under
such  circumstances the existence of fis-
sure  may be  determined with  tolerable
certainty by the symptoms already enu-
merated, and more  especially by  the pain
experienced at every  discharge of faeces
and at all efforts causing a descent of the
anus,  by  its being more severe  at the
moment of greatest distension of this or-
gan;  and by  the faeces  being generally
marked by lines of purulent or sanio-puru-
lent matter from the fissure. When these
signs fail, if the crevice is low, it may be
frequently brought  into view; when this
is not the case, it may still be possible to
ascertain its existence  by the introduction
of the finger, notwithstanding  the pain
caused by the attempt  It is remarked
that the crevice is very rarely found to
correspond with the  mesial line  of the
body, and M. Labat asserts that the num-
ber of cases  in  which several fissures oc-
cur simultaneously is exceedingly small.
When the spasmodic  stricture is so com-
plete as to prevent the exploration  of the
canal, as has been  the case in some in-
stances, the existence of the crevice can-
not be completely  proved,  and the case
must be  considered and treated  simply as
Spasm of the anus (q. v.).
  The prognosis of confirmed  fissure,
when abandoned to the unaided powers of
nature,  is always unfavourable.  It may
continue  for  years  without  producing
death, when the alvine evacuations are
rendered habitually soft by the adminis-
tration of purgatives.   A case of a lady is
quoted by M. Vivent  from the practice of
M. Dupuytren,  in which the use of calo-
mel rendered the condition of the  patient
supportable  for  many years, but she did
not recover.  M. Velpeau declares that
after  an indefinite duration, the disease
destroys the patient or terminates by pro-
ducing some incurable organic  affection.
(Loc. Cit.)  Fortunately the cure may be
accomplished in nearly all cases by proper
medical or surgical measures.
  Of the treatment as well as the diagno-
sis of Fissure, so little was known before
the time of Boyer, that we deem  it  un-
necessary to carry back the history of the
disease  anterior to that period.  Those
who are curious to know the rude mea-
sures sometimes employed  by Albucasis,
and the few facts collected by the  earlier
members of the French Royal Academy
of Surgery, will find a guide to  their re-
searches in the Bibliography to the present
section.
  It seems to be almost universally con-
ceded that in cases of fissure, according
to the restricted definition of the term
which we have adopted, the  application
of emollient or  narcotic topical  remedies
is very  rarely attended with  permanent
benefit, and scarcely ever produces a cure.
Repeated laxative or emollient injections,
fumigations  with warm water,  fomenta-
tions  with various vegetable  decoctions,
general bathing, the hip-bath, opiate sup-
positories, and  unguents, have  all been
employed in a great number of cases, and
have  sometimes rendered the pain more
supportable; but the cases in which cures
are said  to  have been effected by such
means are very few in number and mild in
character. In the very extensive practice 
ANUS. (Fissure.)                           121
of Boyer, there occurred a single instance
of success by such measures; and we are
informed by Dr. Samuel Jackson that he
has recently cured a patient by the con-
tinued application of an ointment  of to-
bacco. The details of the  former case are
not given, and the latter has not yet been
communicated to the public.
   One  of the  favourite  prescriptions of
Boyer, from which he obtained temporary
good  effects, was an ointment composed
of equal  parts of lard, the juice of the
houseleek, the  juice of the garden  night-
shade, and the  oil of sweet almonds.  Of
this mixture, moderately warmed, he in-
 jected into the rectum two or three spoons-
 ful, by a small  syringe, and repeated the
 operation several times in the day.  Du-
 puytren indeed still continues to place
 confidence in the local application of nar-
 cotics, and  has extensively employed the
 belladonna  and datura stramonium.  His
 favourite recipe is as follows: R Axungise,
 3vi.; Extr. Belladonna?, Plombi Acetatis,
 aa 3i. M.
   As has been already stated, this emi-
nent surgeon considers the spasm  of the
sphincters as the primary, and the  ulcers
as a secondary  symptom;  and he appears
to employ the  remedy just mentioned to
produce a relaxation of the fibres,  rather
than  to effect any  change in the  ulcer.
The  ointment  is  spread upon a plug, or
tent of moderate size, which is introduced
several times during the day; and the size
of the tent is gradually increased to that
of the index finger.  " The continual use
of this  ointment during some days  often
effects the complete removal of the pain,
and spares the patient a resort to an ex-
treme and very painful measure." (Lecons
Orales. III. 287.)
   The  number of cases  of success ob-
tained by this  treatment would seem at
first to be very encouraging, but it must
be borne in  mind that M.  Dupuytren in-
cludes under the head of Fissure, not only
the crevices of the middle region of the
anus, but those of the  upper and  lower
regions also.  Now in the two last forms
of disease it is obvious that measures may
prove successful, which  would be  of no
avail in the first: indeed, they do not come
within the range of our definition of Fis-
sure, being ulcerations of constant occur-
rence, and seldom producing spasm;  hence
they occur  and may continue independ-
ently of the  hyperaction of the sphincters,
and even when complicated with  that af-
fection the introduction of a bougie or any
other  substance does not  act upon  them
in the same  manner as in cases of proper
  VOL. 11.           11
fissure. (See \ 2 and \ 10.) It so happens
that in  the only observation reported in
proof of the efficacy of this mode of treat-
ment (chosen, as  the reporters state, au
hasard, from a great number,) the fissure
was very superficial.   The  patient was
completely cured in fifteen days. (lb. 287.)
Indeed,  it appears  that  M. Dupuytren
himself prefers  the  incision  of the part
when the crevice  is seated " at the level
of the sphincter muscle."  (lb. 291.)   M.
Velpeau has made a few comparative ex-
periments  upon the effects produced in
this disease by various  unguents,  among
which he included simple  cerate, and the
preparations  of Boyer  and Dupuytren,
mercurial ointment, &c, and he has been
unable  to detect any difference in their
action.   It may therefore  be  stated that
the  chief weight of surgical  experience
proves that all the topical  measures above
mentioned are merely palliative in fissure
properly so called.
   The  attempt has been made to effect a
cure by changing the surface of the crevice,
by means of actual or potential cautery.
The former agent is reported to have been
employed successfully by Guerin,  but as
Boyer very justly remarks, it could  only
be  employed in those rare cases in which
the crevice is unaccompanied by constric-
tion, unless its action was  extended to the
sphincters, which  it could not be without
inconvenience. (Mai. Chir. X. 135. Note.)
M. Beclard claims  almost constant suc-
cess by  the use of the nitrate of silver,
and the  Reviewer of Dupuytren's Clin-
ical Lectures  in the Med.-Chirurg. Rev.
for Oct.  1834  (p. 327.),  states that he has
found a single touch of this substance to do'
more to allay the spasmodic contraction
of  the  sphincter  than any species of
sedative or narcotic.  The objection just
stated is applicable with nearly equal force
to this mode of treatment.   M. Richerand
and  M. Velpeau both oppose it strongly.
The former states  that  lie  never obtained
any  advantage with it  at  l'Hopital Saint-
Louis, and the latter is inclined to attri-
bute the success of M. Beclard  to  the
dilatation which he practised at the same
time with the  cautery. M. Labat declares
that in  about  twenty cases in  which he
has  employed the nitrate of silver,  the
symptoms  have been  invariably  aggra-
vated.
  The treatment of fissure by dilatation
was so strongly condemned by Boyer (see
(>  2.), that he concludes his remarks upon
this  subject with  these words: "In no
case have  I observed good effects from
this  measure—it has always been useless 
122                            ANUS. (Fissure.)
or hurtful." (Op. Cit. 135.) Until recently,
the opinions of the most eminent surgeons
have responded to this statement but the
plan has at present some warm defenders.
Beclard, Marjolin, Nacquart, and Gen-
drin, have repeatedly  succeeded by it
and M. Dubois, according to M. Velpeau,
maintained that it was always successful
in his hands.
  The dilatation is effected by the intro-
duction of tents or plugs of lint gradually
augmented in size until the resistance of
the sphincter is completely overcome. M.
Velpeau states that he has as yet employed
them only twice, but their effects  have
been so happy that he does not hesitate to
recommend them formally.   The painful
and constricted condition of the organ he
thinks a much  less  important objection
than it appears to be.  It is only necessary
to persist in the treatment without shrink-
ing and to enlarge the tents rapidly to the
greatest possible volume, whatever may
be the resistance of the sphincter.  The
pain,  excessively severe during the first
hours, becomes gradually calmed and  al-
most  disappears by the time the fifth or
sixth tent is introduced. He believes that
practitioners who have sufficient resolu-
tion to  force  their patients  to  submit to
the pain at first, will obtain signal success
by this mode of treatment (Diet, de Med.
edit. 2.  III. 300.)  If the  plan  advocated
by M. Velpeau  is indeed deserving of so
much praise, we  cannot avoid the impres-
sion that less painful and more rapid modes
of dilatation might be devised.
  The attempt to cure fissure by incision
has  been  practised  by many  surgeons.
The first trace of this kind of operation is
fourtd in the writings of Albucasis, who
recommends excoriating  the ulcerations
with  the nail, or scarifying them with a
cutting instrument.  Dionis also scarified
them; but these observations have little
value, because of the imperfection of the
diagnosis. But the method that has proved
successful  in the greatest number of in-
stances is the complete division of the
sphincters, as practised by M. Boyer ; the
constriction being thus relieved, the cre-
vice generally  heals  without  difficulty.
"The manner in which  I  practise  this
operation,"  says this distinguished sur-
geon, "is  as follows:  The  patient  has
taken, three days before, a gentle purga-
tive, and on the day itself, a  laxative In-
jection, to empty the intestinal canal, and
in order that the desire  to  go  to  stool
should not be felt for many days.  I place
him upon his side; as  for the operation for
fistula in ano: I introduce the left  index
finger, covered with cerate, into the rec-
tum ;  I pass a very narrow bistoury, cut
square, and rounded at its extremity, and
laid flat along the finger.  The cutting
edge  of this bistoury  is then directed to-
ward  the right or left side, according to
the location of the crevice; and I divide
at a single cut the intestinal membranes,
the sphincters, the cellular tissue, and the
integuments.   I thus  form a  triangular
wound, of which the  summit corresponds
to the intestine, and the base, to the skin.
It is sometimes necessary to elongate this
incision, and  I make a second cut  with
the bistoury.   In certain cases, the intes-
tine retires before the instrument and the
wound of the cellular tissue extends higher
than  that of the intestine; it is then ne-
cessary to introduce  the instrument de
novo,  into the  rectum, to elongate the in-
cision of the intestine.   When the  con-
striction is extreme, I make two similar
incisions,  one  on the right the other on
the left; and when the crevice  is situated
in front, or behind, I  do not comprehend
it in the incision." (Op. Cit. X.  137.)  The
part is  then plugged with lint  to prevent
immediate union; long compresses are ap-
plied,  and the whole dressing supported
by a proper bandage.  Hemorrhage rarely
supervenes, and slight compression checks
the bleeding.   The first  dressing is not
removed for three days, after which  a
dressing of simple  cerate on lint is suffi-
cient   It should be  frequently changed
during the first few days, and the wound
well cleansed  at each removal.  The  cure
generally requires a month or six weeks,
sometimes more,  and it was complete in
every case in  which it was performed by
Boyer.
   Other surgeons  have not been so uni-
formly successful, for cases of failure are
mentioned by Beclard, Richerand, Roux,
and Lagneau.  Velpeau speaks of two
cases  of death from  this operation, one
after many months, from inflammation and
adhesions of the pelvic viscera, with infil-
trations of pus in the  cellular tissue; the
other  in a shorter time, with entero-peri-
tonitis.  When we consider the number
of patients operated on, these  instances
do not appear  at all remarkable.
   The mode of operating has undergone
but little alteration in the hands of other
surgeons, but it is now generally held im-
portant to interest  the crevice  in the in-
cision whenever  it can be safely done;
and when  there are many fissures,  divi-
sions  more numerous than Boyer thought
necessary, are recommended.   M. Laeat
has indeed invented a peculiar instrument 
ANUS.  (Preternat. Pouches.)
123
for this purpose, founded upon the cysto-
tome of Frere Come, but we do not per-
ceive that it possesses any great  advan-
tages over the simple, blunt-pointed bis-
toury.
  It may yet be considered questionable
whether there exists  a necessity for the
complete division  of  the sphincters in
cases of fissure.  This very severe opera-
tion is founded on a hypothesis, and there
are instances of cure where much slighter
incisions have been  made.   One of the
most interesting of these is the third ob-
servation  of Dupuytren.  (Op. Cit. III.
292.)  The symptoms were  very severe
and complicated, and  the crevices were
numerous.   They  were  all  incised,  but
the  knife was only carried to the depth of
three or four lines, yet the patient reco-
vered promptly and completely.
   We might here enlarge upon the gene-
ral disorder  of the system produced by the
severer forms of fissure, which sometimes
masks the original complaint and deceives
the  inexperienced,  and also upon  the va-
rious complications of the disease; but the
former is common  to all  severe irritations
about the anus, and  the consideration of
the  latter would lead to a mere repetition
of the contents of other sections of this
 article.

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   § 12.  Preternatural Pouches or Cavi-
ties of the Anus.  This  is a peculiar form
of diseases of the  anus,  rare indeed,  but
much less so than  some  that have been
already  described, although it appears to
have escaped the notice of surgical writers.
Though agreeing in location and perhaps
arising  from similar causes  with  some
forms of occult fistula and abscess of this
region,  it differs from  them essentially in
 its progress, symptoms, and requisite treat-
ment. It was first made known to the pro-
 fession by Dr. Physick, under whose care
a case  occurred  very soon after his first
settlement as a  practitioner in Philadel-
phia in 1792—and it was  regularly  de-
scribed by him in his annual course of sur-
gical lectures.   Most of the patients who
have been brought to Dr.  Physick for ad-
vice in consultation by other practitioners,
have  been  thought to  labour under an
 imaginary complaint  or under neuralgia
of the anus; and there is reason to sus-
pect that  some of the cases described as
neuralgic, by various  authors, have been
really instances  of the  disease  of which
 we are now speaking. (See { 1.)
   The symptoms which mark the presence
of these preternatural cavities are as  fol-
lows : The patient sometimes makes little
or perhaps no complaint during the inter-
vals  between  the  stools, but  more fre-
quently  he suffers a continued uneasiness
about  the  anus which varies in character 
124                      ANUS.  (Pretermit. Pouches.)
in different individuals.   Some state that
the sensation  is  indescribable, but  very
uncomfortable; others compare it to the
crawling of an insect within the canal;
while others suffer an intolerable itching,
sometimes  sufficiently severe to  produce
insomnolence and extreme distress.  It is
apt to be most severe at night.   One pa-
tient described the uneasiness to feel like
the pressure of  a ton weight upon the
anus.  Pain is rarely felt except  after a
stool, nor is it  then  present at every eva-
cuation ; several  days may pass over and
several discharges may take place with-
out material exacerbation of the symp-
toms, yet at the  next stool the pain may
be excruciating.   The exacerbation does
not precede the evacuation as it generally
does in  inflammatory affections  of the-
anus, but commonly follows after an inter-
val of a few minutes; it is most severe at
its first attack, and gradually subsides and
disappears  in a few hours.  Dr. Physick
has never  observed  it to be  complicated
with spasm of the sphincters, as is the
fissure of the anus. (See $11.)  When the
finger is introduced into the anus, it per-
ceives no well-defined tumour, and seldom
any other marks of disease.  There is pro-
bably in all cases more or less discharge
from the parts,  but this is not  always ob-
vious ; occasionally the margin of the ori-
fice is bathed with serum or an increased
secretion of mucus,  but  in other patients
nothing of the kind is observed, and if the
discharge takes place it must remain con-
fined within the  external sphincter  until
mingled with the faeces in a common eva-
cuation.  Pus is never observed while the
disease retains  its simple character, but
when it becomes  complicated with inflam-
mations, in  or  about  the part affected,
suppuration does  occasionally supervene.
Such are the rational signs of the disease,
and they are sufficient to furnish a toler-
able diagnosis.  But in this, as  in all other
complaints  of the anus, we  must depend
mainly upon actual examination to deter-
mine its character positively.
  Dr. Physick is  in the habit of exploring
the canal by means of a probe with about
half an inch of its extremity doubled back
upon itself so as  to form a kind of hook,
as was recommended by Heister, Dionis,
&c, in searching  for occult fistulae. If the
uneasiness and other symptoms are really
occasioned by the presence of these cavi-
ties, a little patience and perseverance in
causing the probe to advance and retreat
along the  canal,  so  as to bring the point
to bear successively on various parts of its
circumference, will render their existence
and  character  sufficiently obvious.   The
reverted point passes through a small ori-
fice, and enters a cavity or hollow space
of greater or less dimensions, situated im-
mediately beneath or  within the integu-
ment ; and  it sometimes descends so low
as to become prominent under the exter-
nal skin around the margin of the anus.
The pouch is so exquisitely sensitive, tiiat
the presence of the instrument gives rise to
acute suffering; and so much of its parietes
as is formed by the lining membrane of the
canal is diaphanous,  permitting the silver
to shine distinctly through.  Even when
the cavity is extended  beneath the exter-
nal integuments, the point of the probe is
sometimes visible in the same manner. In
some cases, several of these pouches exist
at the same time. The peculiar site of their
orifice is what we have called the middle
region of the anal canal, or between the
sphincters, and their cavity does not ap-
pear to extend above  the margin of the
internal sphincter.   From  their position,
these pouches are continually liable to re-
ceive small portions of faeces  during the
evacuation of the rectum,  or  the subse-
quent contraction of the  sphincters; and
to this cause may be attributed the violent
pain experienced after  some stools, and its
absence  on  other similar occasions.   The
character of the pain  as to duration ap-
pears to  be plausibly explained  by the
same accident.   When  the particle of
faeces is at first received into the cavity, it
produces  of necessity considerable  irrita-
tion either by its mechanical or chemical
properties, but as it becomes softened or
diluted by the secretions of the part  it is
rendered  gradually less stimulating,  and
at last  it may be partially or  wholly re-
moved by the discharge;  hence the  gra-
dual subsidence of the pain and its  fre-
quent cessation after a few hours.   The
fact of the reception of such foreign mat-
ters into the cavity is placed beyond doubt,
for Dr.  Physick  has actually discovered
and  removed  minute  portions of faeces,
and, in one instance, a small seed so situ-
ated, at the moment of operation.
  We will also venture to suggest a  pro-
bable explanation of the fact that the ac-
cess of pain does not generally take place
in the act of defecation, but rather a few
minutes after the discharge has been com-
pleted.  A cavity located as these are, and
having but a small orifice and very flexibln
parietes on the side next the canal, must
be necessarily compressed during the  pas-
sage of fieces; its cavity must be nearly or
quite obliterated, and its contents chiefly
or entirely expelled;  it is  therefore not 
ANUS. (Preternat. Pouches.)                      125
very likely to arrest any part of the mass
in transitu, particularly as there is no par-
tial septum, but rather an enlargement of
the canal at the spot where the orifice is
located.  But  it is well  known that  the
middle region of the anus is rarely per-
fectly evacuated when the faeces are at all
firm in consistence; some portions are ex-
tremely apt to remain in the slight  en-
largement  existing between the sphinc-
ters.  Now it appears to us that after the
contraction of the sphincters, the sides of
the cavity being in a great degree relieved
from pressure,  and its orifice flaccid, the
liability to the admission of minute por-
tions of faeces  must be much increased.
This remark may be regarded by some as
speculative and as not very important but
the peculiar time of the access of pain is
important in the diagnosis, and nothing
should be neglected that tends in any de-
gree to disentangle the confusion in which
the diseases of' the anus and rectum have
been involved.
   On the cause of the preternatural cavi-
ties of the anus, Dr. Physick entertains
some views which can hardly be regarded
as speculative.  In his opinion, they  pro-
bably commence in the same manner with
one of the forms of hemorrhoidal tumour.
The constriction of the sphincters, which
embarrasses the venous circulation of  the
part aided by the pressure exerted in pass-
ing difficult stools, frequently give rise to
ecchymoses beneath the integuments. The
effused blood produces no irritation of the
cellular tissue in  which it  is placed,  but
forms  for itself a  simple inert receptacle.
If the blood  is neither absorbed nor dis-
charged, but remains or becomes enlarged
by successive ecchymoses,  it constitutes
(certain  authorities  to the contrary,  not-
withstanding,) one  form of  hemorrhoid.
If, on  the  other hand, some accident, or
the absorption of the integument gives
exit to the blood  after the cavity has be-
come accustomed to its presence, the  cel-
lular tissue shows little disposition to re-
unite,  no obvious marks of inflammation
appear, and  a preternatural cavity is es-
tablished.
   In support of this explanation, which is
urged with characteristic caution, as an
hypothesis, Dr. Physick states that in the
early part  of his practice, he has in seve-
ral instances operated on hemorrhoidal tu-
mours of the same part, in which, after
the  removal of the coagula, the part pre-
sented precisely the same aspect with the
preternatural  cavities,  wanting only  the
orifice; he refers also to the existence of
similar cavities after the discharge of ec-
                  11*
chymoses of the  scalp, such as most sur-
geons  must  have  seen,  particularly  in
children,  and which  often prove tedious
and difficult of cure; he has also witnessed
the same accident in other  parts of the
body.  In most cases  the first appearance
of the cavities was preceded by trouble-
some piles.
  The diagnosis of this  affection  is not
very  obscure.  It  is  distinguished  from
ruptures and ulcerations  of  the  superior
portion of the canal,  and from superficial
inflammations, by the absence  of all con-
siderable discharges either of pus or mu-
cus, and by the freedom from that gradu-
ally increasing pain which occurs, in such
complaints, from  the pressure of the faeces
accumulating above the sphincters.   It is
alike distinguished from  the  cases just
mentioned, and from  fissure  of the anus,
by  the occasional absence of all pain at
stool, and also by  the moment of the great-
est suffering being, in this disease,  some
time after the evacuation, whereas, in the
others, it is at the moment of the passage.
From neuralgia  of the anus, with which
it has been frequently confused, it is widely
removed by the regularity with which the
function of defecation is  performed; the
absence of all marks of irritation  in the
urinary apparatus; the strict relation be-,
tween the stools  and  the  access of pain;
and, in many cases, the excessive pruritus
complained of in the  intervals.  It is very
remarkable also,  that  the preternatural ca-
vities have  never yet been  seen compli-
cated with spasm of the sphincters.  There
remains but one disease for which it might
be  mistaken; this is the occult fistula, and
it  is particularly important  to point out
the essential differences between  these
complaints, because of the opposite plans
of  treatment which  they   require—not-
withstanding their common  location, and
the similarity, in  many  respects,  of the
causes which produce these cavities and
also  some forms of  the  fistula.  Occult
fistula  is always preceded by inflamma-
tion, and generally  by abscess, with its
well-marked train of symptoms. (See 1} 13.)N
Even when it succeeds the  rupture of a
hemorrhoidal tumour, it  is  preceded,  or
immediately followed by suppuration (Ri-
bes,  in Mem. de la Soc. a"Emulat.); and
this is likewise the case when it originates
in a perforation of the intestine by ulcera-
tion  or  mechanical injury.   The  cavity
formed by the fistula is more deeply seated,
and modern  experience proves that it is
altogether unnecessary to remove consi-
derable portions  of the walls of the  ab-
scess, as was done by ancient surgeons; 
126                      ANUS.  (Preternat. Pouches.)
for a simple incision, laying the whole ca-
vity open to the canal, is found sufficient
to effect a cure.  (See § 14.)  When por-
tions of the integument were removed in
fistulas, it was found that  the  loss of sub-
stance occasioned contractions of the cica-
trix which sometimes interfered  materi-
ally with the due exercise of the proper
functions of  the part.   The preternatural
cavities of the anus, ol the contrary, are
not preceded by marks of inflammation.
Even if caused by the evacuation of a he-
morrhoidal tumour,  no suppuration fol-
lows, but the cavity remains sluggish and
indisposed to contract adhesions by which
it might be obliterated.  It is always su-
perficial or situated immediately beneath
the integuments.   Moreover^ it is neces-
sary to remove the greater part of the in-
ternal  covering of the  cavity, together
with the orifice, in order to insure a cure;
for if any portion is allowed to remain be-
neath  the orifice, the same sluggishness
of tissue  may continue in this remaining
part, and after the wound produced by the
operation has healed,  a cavity of smaller
dimensions may still subsist, and give rise
to a return of symptoms.  After the exci-
sion of the  inner parietes, no disposition
to retraction  in consequence of the loss of
substance is evidenced by the  cicatrix, or
at least no such disposition has been yet
observed in any case not complicated with
other diseases; a circumstance that proves
the wide difference between the condition
of this  cavity and  that of a suppurating
or granulating surface.
   The  mode of operating, devised by Dr.
Physick for  the relief of this complaint,
(one which has proved successful in every
instance,) consists  in drawing down the
membranous  covering of the cavity by
means of a bent probe, and then removing
the whole of this portion, or as much of
it as possible,  by the scissors,  taking care
to include the orifice by which the probe
enters,  in the part excised.  The opposite
surface is thus laid completely open to the
anal canal. It must be borne in mind that
several of these  cavities may  exist at the
same time, and  that  after the patient is
relieved by the cure of these,  others may
be formed consecutively, in some instances.
In one case particularly,  numerous opera-
tions were successively performed during
a period of several months, for the  extir-
pation of a series of these sacs, which were
developed, one after another, on the same
side of the canal, in the same individual.
The surgeon should therefore repeat the
operation  as often as necessary, until the
complaint is effectually eradicated; and it
 is evident that due attention to the habit-
 ual condition of the bowels, so strongly in-
 sisted on  in  the preceding  sections,  is
 equally imperative here, if we would com-
 pletely remove the causes of the disease.
   We  cannot quit the present subject
 without expressing the pleasure we enjoy
 on this, as on all other occasions, in se-
 curing to the  rightful claimant  the credit
 of services rendered to humanity; yet it
 is mournful to reflect that the  vast funds
 of knowledge and experience accumulated
 by one who has  filled, so  long and so ho-
 nourably, the first station among Ameri-
 can surgeons, should remain accessible to
 but a small portion of the  medical public.
 They lie chiefly buried in his own mind,
 or in the memory of those who have en-
 joyed the happiness of attending his deeply
 impressive  discourses.   Abroad, a great
 surgeon whose  avocations prevent  him
 from publishing the results of his experi-
 ence, has always his reporters. The novel
 opinions of Sir A. Cooper, of Dupuytren,
 &lc, reach us, almost as soon as uttered,
 through the medium of the press;  but on
 this  side of the  Atlantic,  we  have been
 shamefully  negligent of our own  claims
 to distinction.  That no one who has en-
 joyed the privilege of hearing the clinical
 remarks and  the public lectures of Dr.
 Physick, has stepped forward to do justice
 to the Professor and the Profession, is not
 only a matter  of surprise, but a just cause
 of national regret. How small  a portion
 will be ultimately rendered to  Cassar, of
 all that  bears his image and superscrip-
 tion!
   § 13. Abscess of the  Anus.  The neigh-
 bourhood of the anus, like all other parts
 in which free cellular  tissue  abounds,  is
 subject to the  several varieties of abscess,
 and  it is remarkable that inflammations
 of this region almost invariably result in
 suppuration, unless they are confined to
 the integuments.  Boyer  observes that
 even in those rare cases which apparently
 terminate by  resolution, it is possible to
 detect a nucleus  or induration, more or
 less  deeply seated,  which remains,  and
 ultimately gives rise to a consecutive ab-
 scess. (Mai. Chir. X. 101.)
   The varieties  observable in the  symp-
 toms and progress of these affections are
 chiefly owing  to  the peculiarities in the
 anatomical structure of the parts where
 they are located.  Thus, those which occur
 at a  considerable  distance  from the anal
orifice, near the  nates, and between  the
skin and superficial fascia, are seated in a
dense, adipose, and fibrous  cellular tissue.
The  superficial  fascia generally prevent 
ANUS. (Abscess.)                           127
them  from extending deeply, toward the
pelvis, and the character of the tissue op-
poses the formation of sinuses; they there-
fore present in most instances, that  cir-
cumscribed,  anthracoid  appearance  to
which we alluded in the section on Inflam-
mation.   Those which are situated nearer
to the orifice, or within its verge, but exte-
rior to the superficial fascia, are commonly
circumscribed, at first, in  the same man-
ner.   They are  generally small, and are
called tubercular abscesses, from the form
of the little tumour immediately beneath
the integument, in which the suppuration
takes place.  Those that are wholly or in
part internal, are termed also hemorrhoidal
abscesses.  The close adhesion of the skin
along the mesial line, renders it difficult
for the pus to travel from  one side  to the
other, but there is  much less resistance to
its progress in the direction  of the anus,
and  the  formation of a sinus or external
blind fistula is often the  consequence of
tuberculous abscess, even when seated at
a considerable distance from  the anus, on
the perineum (see § 14.); and when it  is
located  within the  verge, the continual
engagement of fecal matter, or the secre-
tions of  the part in the orifice of the ab-
scess, may occasion true fistula.
   When the  mflammation attacks  more
deeply seated parts, it is usually accom-
panied by all the well-known  marks of
phlegmonous abscess; the local and con-
stitutional symptoms being severe in pro-
portion to the importance of the function
and the extensive sympathies of the anus.
   The most common seat of the phleg-
monous  abscess is the  recto-ischial exca-
vation.  The texture of the cellular tissue
here permits of a free extension  of the
cavity in several directions, and it rarely
fails to  involve all the space between the
rectum within; the  ischium and obturator
fascia, without;  the aponeurosis of the le-
vator ani, above; and the  superficial fis-
cia  and  integuments below.   This great
sac  seldom approaches the surface, until
it has denuded  and thinned  the parietes
of the intestine to a considerable extent;
but it may not evacuate its contents into
the  rectum, when competent surgical aid
is invoked in time, even in  casps which
originate primarily from  some lesion of
that organ. If neglected, still greater ex-
tension may be given to the cavity, which
then reaches the os coccygis, and as the
aponeuroses are by no means insuperable
bars to the progress of an abscess, the pus
may  not only extend upward along this
bone and the sacrum, but may even reach
the  meso-rectum,  and pass  beyond any
assignable limits.  Though the  raphe in
front of the anus offers considerable oppo-
sition to the enlargement of the  cavity, it
does not in all instances arrest  it, and in
the  neighbourhood of  the  os  coccygis
this barrier scarcely exists; nevertheless,
phlegmonous abscess  in the recto-ischial
excavation is usually confined to one side,
and  if both sides become affected, they
are generally attacked at different periods.
In some cases, however, a  single abscess
has been known to denude nearly or quite
the whole circumference of the  intestine.
  When disease  of this character occurs
in the thickness of the levator ani muscle,
the pus  is confined between the  pelvic
fascia above,  and the aponeurosis  of the
muscle  below, so that  it naturally tends
toward the rectum, in preference to taking
any  other direction, and generally opens
into the intestine before it produces any
very decided tumour externally.  Its pre-
sence is often more readily determined by
the  introduction  of the  finger into the
anus, than by an external  examination.
  When  there exists either a primary or
secondary communication between the ca-
vity and the canal of the intestine, giving
entrance  to portions  of fecal matter, the
case is denominated a stercoraceous  ab-
scess ; but as  the existence of such a com-
munication  has an important bearing on
the treatment, it is proper to state that the
decided fecal odour and brownish  colour
so  frequently  observed in  the  discharge
from abscesses about the anus, when first
laid open, are not sufficient proofs that the
integrity of the intestine is lost; for these
appearances are common in all collections
of fluids  remaining long confined  in the
neighbourhood of the  rectum,  owing to
the transpiration which is now well known
to  take place through all animal mem-
branes. (See Abdomen, abscesses of. Vol.
I. p. 78, &c.)   M. Velpeau lays  particular
stress on this fact (Diet, de Med. III. 311.)
   Phlegmonous abscess of the anus is al-
ways very rapid  in its progress, and pro-
duces, in addition to the well-known local
and general symptoms  of the same affec-
tion  in other  parts, the following  conse-
quences which are peculiar.   The anal
canal is diminished by the swelling occa-
sioned by the sac, which not only opposes
a mechanical impediment  to the passage
of the faeces,  but, in consequence  of the
extreme sensibility of the inflamed parts,
renders  the  performance of the function
of defecation excessively painful. A dread
of  evacuations,  and generally, decided
costiveness, are  attendant on the disease.
The  irritation is also extended to the 
128                            ANUS.  (Abscess.)
bladder and urethra, and the discharge of
urine is  frequently  rendered difficult—
sometimes impossible.  When the tumour
is  seated in the recto-ischial excavation,
the fever and other  constitutional symp-
toms are at once  explained  on  a careful
examination; but when it occupies a sta-
tion above the aponeurosis of the levator
ani, these  symptoms are often more per-
plexing, because the  swelling and hard-
ness of the inflamed part are concealed by
its depth.  In such cases,  if the  finger be
introduced into  the anus,  a  rounded tu-
mour is detected at a greater or less dis-
tance from the  orifice, encroaching upon
the canal; it is often as large as a nutmeg,
or larger; well defined; hard, or exhibit-
ing signs of fluctuation, according to the
stage of the complaint; and almost always
confined to one side of the intestine.
   Gangrenous abscesses  of  the anus are
usually still  more extensive than  those
just described.  They appear to be various
in their mode of attack and in the rapidity
of their progress, nor is  the history of
their several forms sufficiently  complete
to explain the  nature of  all these varie-
ties.  Both the anthracoid tumours seated
near the nates, and  the  diffused cellu-
lar inflammation of the anus, which are
sometimes classed with  gangrenous ab-
scess,  have  been  already  noticed,  when
speaking of Erysipelas, in } 6. of this ar-
ticle.  Of the remaining  cases,  some are
very rapid in their progress, and are at-
tended with the usual symptoms of deep-
seated  phlegmonous inflammation; others
are slow in forming, excite but little fever,
almost no pain, and are usually attended
by  marks of considerable  constitutional
depression.  The hardness is always very
deeply seated and obscure  at  first,  and
neither softness nor fluctuation are  per-
ceptible until the disease is very far ad-
vanced;  when the tumour generally in-
volves  a large portion of the  nates.   The
integuments then feel doughy or pasty on
pressure, from the presence of oedema;
they assume a livid hue, and one or more
escars  soon  make their appearance,  into
which  a stylet will penetrate almost with-
out  resistance.  (Boyer.  Mai. Chir. X.
100.  Sabatier. Med. Operat.  II. 162.)
It is hardly necessary to state the extent
to which the loss of substance may be car-
ried in cases of this character, especially
if the  abscess be not opened at an early
period; but it is remarkable  that the ab-
scess is  almost always confined to  one
side, and very  rarely involves the whole
circumference of the anus.
   Besides these forms of  the disease, the
anus is sometimes the seat  of abscess by
congestion (q. v.), and abscess symptomatic
of phthisis.  Occasionally, collections of
pus in other parts, such as the lumbar
region (see Psoas abscess), make their
way into the  pelvis  beneath the peri-
toneum or along  the  mesc-rectum,  and
finally reach  the  surface,  at  the  anus.
Critical abscesses,  which are not very un-
usually met with in this  part, are  gene-
rally of the phlegmonous character.
  Of the diagnosis little need be said;
the symptoms already laid down are suffi-
cient in most cases. It is thought possible
to confuse the gangrenous abscess of the
anus, with that which arises from infiltra-
tions of  urine  into the cellular tissue—
but without considering the disorders of
the urinary apparatus which precede  the
formation of the tumour in the latter com-
plaint, and which are sufficient  in  them-
selves  to determine its nature  from  the
commencement, there is a peculiar blanch-
ed appearance and a urinous smell of the
flakes  of dead  cellular tissue  discharged
on opening an abscess of this character,
which is at once  distinguished from the
true stercoraceous or common gangrenous
odour of the former variety.
  On the causes  of abscess of the anus
much has been written, and several of the
highest authorities have selected each his
favourite cause, to which he has attributed
nearly all the cases,  to  the  neglect of
other important sources of mischief;  and
this habit has sometimes led to narrow and
exclusive practical views.  There is  really
no mystery in the  case. The disease may
spring from any of the causes which  pro-
duce similar affections in other parts,  and
also from a variety of accidents obviously
dependent on the peculiar structure of the
anus  and the lower part of the rectum.
Avoiding all discussion, we  shall enume-
rate very rapidly  the more  important
causes, with the  names  of some of the
writers who  have  particularly noticed
them,  and shall complete the details of
the references  in the bibliography, to  pre-
vent confusion  in the text.
  The causes of tubercular abscesses are
either internal or external.   Of the for-
mer class are, 1.  ulcerations  or crevices
formed by internal hemorrhoids which em-
barrass defecation (Sabatier), and  which
are said, by some, (we think, erroneously,)
to give rise to actual infiltration of sterco-
raceous matter or of the vitiated secretions
of the part into the cellular tissue (Boy-
er) ;  2. the attrition  of fieces, or foreign
bodies, in their passage (Velpeau);  3.
the irritations  and ulcerations occasioned 
ANUS. (Abscess.)
129
by the lodgment of faeces and vitiated se-
cretions in what we have denominated the
middle region of the anus (Larrey) ; 4.
the ulceration of a hemorrhoidal vein (Ri-
bes). Abscesses produced by these causes,
when allowed to open spontaneously, gene-
rally pour out their contents into  the ca-
nal ; giving rise to  blind internal fistula,
improperly so called, and do not acquire
an external  orifice  until some time has
elapsed.
  The external causes are those which occa-
sionally produce pustular tumours in other
places; such as mechanical or chemical
irritations of the skin; the bites of leeches
(Danyau) ; stimulating  discharges, &c.
Abscesses  produced by such means often
give rise  to  external blind fistula.  If a
communication with the rectum is  ever
formed, it  is not till after a considerable
period, and is more apt to take place at
some distance above the anus, than in the
former variety.
  The more extensive abscesses of the
anus, whether phlegmonous or gangrenous,
rapid or slow in their progress, generally
arise from similar causes.  The phlegmon-
ous and the rapid cases are met with most
frequently  in persons of  hale  appearance
and a certain degree of embonpoint. (Boy-
er.)  The rapid and gangrenous cases are
probably caused  by the actual escape  of
stercoraceous matter through considerable
rents in the  rectum, and they almost al-
ways commence at a great depth.  Those
which are longer in  reaching the surface
are generally of vast extent and are con-
nected with peculiar constitutional condi-
tions, which have not been sufficiently in-
vestigated.
  All these forms  of the disease may ori-
ginate from external violence, such as se-
vere contusions  (Marchand) ;  but a vast
majority of  cases  result  from internal
causes either  in the rectum, or in other
and sometimes distant parts.   Of the for-
mer  class are, punctures  or lacerations of
the intestine by sharp-pointed foreign bo-
dies, such as pins, needles, fish-bones, &c,
or the  irritations  produced by the lodg-
ment of similar substances or hardened
fiEces  in the follicles above the internal
sphincter.  (Sabatier.)   Instances of ab-
scess originating in or above the levator
ani,  are sometimes, though  very  rarely,
found  to contain pieces of bone or other
hard bodies which  have escaped from the
alimentary canal (Velpeav) ; and  the re-
cords of surgery are rich in cases of ab-
scess from  the presence of foreign bodies.
A vast variety of substances of all sizes,
from a table-fork introduced per anum, to
a small seed which has traversed the bow-
els,  have  been occasionally  discharged
from abscess of the anus. (See Bibliogra-
phy of this section, and Art. Rectum.)
Among the mechanical causes of this class
may be mentioned some gun-shot wounds,
and injuries inflicted by the syringe.
  The venereal ulcerations, and those re-
sulting from dysentery, &c, may also oc-
casion these abscesses; and M. Velpeau
is inclined to attribute those forms of the
complaint which  appear after severe fe-
vers,  and   in  patients labouring  under
phthisis, to ulcerations of the rectum simi-
lar to those observed in other parts of the
alimentary canal.   But by far the most
frequent of this class of causes, is said to
be the irritation of internal hemorrhoids.
  The internal causes  of large abscesses
of the anus are scarcely  less numerous.
Among them are the following: caries or
other disease of the os coccygis or sacrum
(Hawkins), of the ischium (Velpeau), of
the  dorsal  vertebrae (lb., Ribes),  and  a
variety of supposed metastases.
  Treatment.   The  detail of the various
precautions  rendered  necessary  in  the
treatment of a disease so various in its
extent and in  its causes, would lead us to
encroach extensively upon matters which
are  more properly discussed under other
heads.  We shall therefore confine our-
selves as much as possible to those points
which have a peculiar relation to abscesses
of this region only.
  It has been remarked that resolution is
almost impossible  in cases  of this kind,
but  it is of the highest importance to pre-
vent the undue extension  of the purulent
cavity, because the extensive loss  of sub-
stance which  always results from these
abscesses  is the chief cause of the diffi-
culty and danger which they occasion. A
moderate antiphlogistic treatment should
be instituted,  to check the extension of
the tumour; and the usual measures should
be employed to hasten the formation of
pus.   No  principle  is better  established
than that abscesses  of  the anus should be
opened at least as  early  as the first ap-
pearance of fluctuation, however obscure
it may be; and there are not wanting, au-
thorities  both  ancient  and modern, who
advocate this  step  at  an earlier  period.
(Platner, Velpeau.)
  With regard to the manner of operating,
there is much greater difference of opinion.
The use of caustic, once in vogue,  is now
totally abandoned, and the bistoury is uni-
versally employed.   With regard  to  the
form,  number, and  direction of the inci-
sions, very various  directions  have been 
130
ANUS. (Abscjsss.)
 given, but it is unnecessary to notice them
 particularly, as the best surgeons agree
 in stating that the danger of hemorrhage
 is not to be dreaded.   There  is perhaps
 some convenience in making the principal
 incision in a line parallel to the anus, but
 it is of infinitely more  importance that
 the opening should be so formed as to give
 the most ready egress to the pus, and that
 its dimensions should  be ample, except
 perhaps in abscesses from congestion, and
 in those vast collections of pus  which
 sometimes  make  their way to the anus
 from very distant  parts, cases which will
 be more properly considered under other
 heads.   Tuberculous abscesses are  best
 treated by transfixing them in the direc-
 tion of their long diameter,  and dividing
 them completely by a single stroke of the
 knife.  In those which mount above the
 sphincter without extending far from the
 coats  of the anus, M. Velpeau recom-
 mends a bistoury to be  carried into the
 anus, so as to divide the cavity from within
 outwards, toward  the nates; a plan attri-
 buted to J. L. Petit, and which may some-
 times prove  convenient.
   In  those  cases  of  phlegmonous ab-
 scess  seated  in  or above  the  levator
 ani, and  which are detected  by the  intro-
 duction  of the finger  per anum, before
 they have perforated the aponeuroses and
 become  visible externally,  there is no
 question  of the propriety of the plan ad-
 vocated  by  the  author  just mentioned,
 which consists in sliding a  bistoury laid
 flat along the left finger, to the seat of
 the  swelling,  and then  opening  the ab-
 scess  from  the rectum  by  turning the
 knife, without dividing  the sphincter. Of
 course, the bistoury used for this operation
 should be guarded through a considerable
 portion of its  length, to prevent injury to
 the lower part of the canal.  The danger
 of forming a blind  internal fistula is not
 considered a valid objection to this  mode
 of treatment by M. Velpeau, and a patient
 on whom he operated in 1828, by making
 a large  opening, recovered completely in
 eight days. (Diet, de Med. III. 313.)
   The great difficulty attending the  treat-
 ment  of the other large  abscesses of the
 anus is the extensive denudation and thin-
 ning of the rectum and integuments, and
 the  frequent occurrence  of a primary or
'secondary opening in the parietes of the
 intestine, which admits of the constant in-
 troduction of portions of fecal matter. The
 former circumstance renders cicatrization
 difficult,  by retarding  or preventing the
 formation of granulations over a consider-
 able portion  of the parietes of the cavity,
and the latter endangers the formation of-
a fistula,  or  may cause a succession of
new abscesses.
  These  considerations induced  Facet
(faine) to urge the propriety of invariably
dividing the rectum, from the highest point
of denudation,  to the  anus, at the same
time that the abscess  is opened, so as to
throw the two  cavities into one.  It has
also been advised, by others, that any por-
tions of intestine or integument which are
so far  enfeebled as to 'retard the union,
even when divided, should be removed at
once—and Faget himself successfully ex-
tirpated an inch and a half of the rectum,
for this purpose, without producing incon-
tinence.   M. Foubert published soon af-
terwards an  essay in opposition to these
views, advocating the propriety of simple
punctures without involving the intestine,
defending his views by details of several
successful cases, only three of which are
strictly relevant.  The opinions of these
writers have divided the profession until
recently,  and  have had perhaps more
weight than  they justly deserve, for the
number of their observations is very small.
It is now well known that abscesses of
the anus, whether arising from  internal
or external causes, are often totally un-
connected with the intestinal canal, even
after  they have denuded the rectum to
a great extent; and  the cases  are  nu-
merous, in which external incisions,  and
the evacuation of the  pus, have been fol-
lowed  by  prompt and complete cures.
(Marchand,  Sabatier.) Even when there
exists  such a communication, it is gene-
rally located at no great distance from the
anus, and by no means requires the ex-
tensive division recommended by the for-
mer surgeon. (Boyer.) Moreover, fistula
is not in all cases a necessary consequence
of such a  communication,  and the conse-
cutive operation  rendered necessary by
this complication when it does take place,
is not  now considered  of as much impor-
tance as it formerly was.  On the other
hand, surgeons now recommend extensive
incisions instead of the simple puncture,
of M. Foubert ; for instead of increasing
the danger of exhaustion and of excessive
irritation,  by  making a free orifice, we ac-
tually  diminish it.  The  quantity of the
pus secreted, as M. Velpeau very justly
remarks, depends not on the extent of the
opening, but  on that of the cavity, and its
irritation  is rendered  infinitely  more se-
vere by the  confinement  of a portion of
pus in the cavity after having undergone
the partial action of the  air, than by the
exposure of the whole  surface.   M. Mar- 
ANUS.  (Fistula.)
131
chand attributes many of the cases of con-
secutive abscess,  so  much feared by  M.
Facet when the  integrity of the rectum
was preserved, to  the habit of making too
small an  opening and then  interrupting
the flow  of the  discharge by  improper
dressings.
  It is  now conceded, that when the  ab-
scess is not very extensive, when it is in
close proximity to the anus, and  does  not
rise above  the sphincter, the method of
M.  Facet is  in  some degree preferable;
that when it  is larger, and its communi-
cation with the rectum is  easily detected,
the intestine should be laid open  from  the
internal orifice down to the outlet of  the
anus;  but that when the  communication
is placed  very high in the canal,  or when
it escapes observation, the  external inci-
sions alone, should be practised.
  The best position for the patient during
the operation is either that recommended
in  fissure (see $ 11.), or  that commonly
employed in fistula (6ee § 14.). The  nates
being sufficiently parted by an  assistant,
and the form  of  the incision determined,
the surgeon introduces his bistoury to  the
proper depth,  and enlarges the  orifice by
retracting it.   He then introduces the in-
dex finger of the  left hand into the cavity
to  examine the  condition of the integu-
ments and the intestine, and to ascertain
if there is a  necessity for any additional
incisions  for the removal of culs-de-sac, or
other obstacles to the flow of the pus.   If
the abscess is stercoraceous, it may be
proper to introduce the other index finger
into the rectum at the same  time, to de-
tect,  if possible, the seat of the internal
orifice.   The  wound should be  the most
dependent  part,  and,  if  practicable, it
ought to be at least coextensive with the
cavity.   The only dressings required are,
a pledget of lint applied in such a manner
as  to secure  a union from the bottom of
the cavity, and to prevent the formation
of  partial, or  irregular adhesions; a poul-
tice : and a double T bandage to support
the whole. After a short time, the case
may be treated as a common wound.  The
cure generally requires from six  weeks to
two months;  and after a few weeks have
elapsed, the patient  should be placed on
a generous diet   Free air,  if possible,
in  the  country,   and every safe measure
calculated  to  produce embonpoint should
be  employed.  All surgeons agree in  lay-
ing great  stress upon this rule in  the
treatment both of abscesses and  fistulae, as
the increase of adipose matter is of pow-
erful assistance in approximating the pa-
rietes of the  cavity formed by so great a
loss  or  condensation of substance.
  Bibliography.—Saviard.  Observations Chi-
rurgicales.   Paris, 1702.  8mo.  Translated into
English.  London,  1760.
  Faget. Remarques sur les abces qui arrive an
fondcment.  Mem. de l'Acad. Royale de Chi-
rurgie.  I. 289.   Edit in 8vo.  Paris, 1819.
  Foubert. Sur les grands abces dufondement.
Mem. de l'Acad. Royale de Chirurgie.  III. 431.
Paris, 1819.
  Brasdor.  De ani abscessibus. Paris, 1761.
  Pott.  Chirurgical Works.   London, 1771.
Edit, by Earle. 111. 77-82.  London, 1790.
  Marchand.  Sur le traitement des abces oue
surviennent aufondement.  Journ. de Medecine.
XLIV. 439.   Paris, 1775.
  Petit.  Traiti  des  maladies chirurgicales.
(Euvre poslhume. II.  100.  Paris, 1790.
  Sabatier. De la midecine opiratoire.  Paris,
L796.  Edit. 2d.  II. 160.  Paris, 1810.
  Larrey.  Mimoires  de chirurgie  mililaire.
Edit. 2d.  Translated by Hall.   II. 373.  Balti-
more, 1814.
  Montagnon.  Riflexions et observations sur
les abces aufondement. Ann. Cliniques de Mont-
pellier. XXXIII. 355.  (1814.)
  Boyer.  Traiti de maladies chirurgicales.  X.
99.   Paris, 1825.
  Velpeau. Compte rendu des principales mala-
dies  chirurgicales observie  a  I'hopital  de la Fa-
culti, &c. Obs.  iv. et v.  Archives  Generates.
XI. 336.  Paris, 1826.
  Ribes. Mimoire sur la situation de I'orifice
interne de la fislule d I'anus. Mem. de la Societe
Medicale d'Emulation. IX. 115-134. Paris, 1826.
  Hawkins, (Caesar.)  Cases of abscess in  the
pelvis; with clinical remarks.  London Medical
Gazette. X. 817. (1832.)  Copied in  American
Journ. Med. Sciences. XI. 503.  Philadelphia,
1833.
  Danyau, (A.  C.)  Des abces a la  marge de
I'anus.   Theses  de concours pour  l'agregation.
4to.  Paris,  1832.
  Velpeau. Art  Anus, in Diet, de Medecine.
Paris, 1833.
  Kirkbride.  Case of extensive sloughing about
the anus. Clinical Reports, in American Journ.
Med. Sc. Philada. Feb. 1835.
  See also  the general treatises on the diseases
of the anus and rectum, and the  Bibliography
of § 4. and § 6.

   §  14. Fistula in Ano.  This  term is ap-
plied  to  many  suppurating excavations
about the anus, which do not come strictly
under the definition  of Fistula  (q. v.) as
generally  described  by authors;  for  al-
though the disease is sometimes found to
consist in  a long, narrow, and tortuous  ul-
cer  opening upon the integuments by one
of  its  extremities,  almost always  sur-
rounded by some callosities, and often  by
very extensive induration, it is not unfre-
quently dilated into one or more caverns,
either  confined  to the  neighbourhood  of
the  rectum, or extending in other direc-
tions through the  cellular  membrane  of
the  pelvis.  Sometimes it appears as a
considerable  cavity with  many outlets 
132
ANUS. (Fistula.)
(cavernous abscess); at others, as a sinu-
ous  canal, with several ramifications all
finally terminating in one orifice (sinuous
ulcer).  The discharge from this cavity is
generally small in amount  and presents
the characters of pus, gleet sero-purulent
sanguineo-serous or mucous matter, accord-
ing to the condition of the patient's health,
and  the length of time during which the
affection has  subsisted.   Fistula in  ano,
then, is a suppurating cavity of consider-
able  extent seated in the neighbourhood
of the anus or rectum, varying in form,
having little tendency to become  sponta-
neously obliterated, but continuing  for a
long time  to discharge  its  secretions
through one or more narrow openings in
its parietes.
  1.  Causes of Fistula. As this complaint
is almost, if not always, preceded by ab-
scess, it  may originate  from  all those
causes, whether  local  or constitutional,
which have been enumerated in the pre-
ceding section; but of these, by far  the
most frequent are the irritations giving
rise  to the  tuberculous  form of abscess,
hemorrhoids,  and  the  arrest  of foreign
bodies in the lower part of the rectum.
Caries of the vertebra, sacrum or coccyx,
&c, are more rarely productive of fistula
in this region; but there are many cases
of this nature on record.   Dr. Dorsey re-
lates a very remarkable one, in which a
psoas abscess terminated near  the anus,
was  opened, discharged a gallon of pus,
became obliterated, but left a fistula which
required an operation for its relief. (Elem.
of Surg. II. 160.)
  There are two distinct modes in which
an abscess may give rise to fistula. In the
first  place, when it is seated at a consider-
able  depth, as  is mostly the case except in
the tuberculous or hemorrhoidal variety,
there is sometimes a considerable loss or
destruction  of the cellular tissue around
the anal canal; and even  if this accident
does  not occur, there is nevertheless a
condensation or induration,  produced by
the internal  adhesions of the tissue,  obli-
terating the cells around the  periphery of
the depot (See Art. Adhesion.  I. 211. 2.
a.)   Now the  constriction of the sphinc-
ters keeps the parts around the  anus  con-
tinually in a  state of moderate tension,
except during the act of defecation, and it
is evident that when there is a cavity
with loss of substance, or indurated walls,
in these parts, the parietes cannot be pre-
served in contact except by surgical mea-
sures.  We  are not yet in possession of
any  efficient plan of treatment for  this
purpose, and the peculiar structure  and
 functions of the anus render it extremely
 improbable that it will  ever be  accom-
 plished.  Moreover, the induration of the
 parietes embarrasses  the development of
 granulations, and  renders it difficult  for
 the operations of  nature  to effect that
 which thus baffles the surgeon.
   The same sources of evil exist in the
 structure of the recto-ischial excavation
 (see Perineum),  in consequence  of the
 tension  of the aponeuroses by which it is
 surrounded; but the frequent expansion of
 the rectal pouch by faeces, the pressure of
 the movable viscera, acted on by the abdo-
 minal and levatores ani muscles, and the
 flexibility of the deeper aponeuroses of the
 pelvis, render almost certain the collapse
 of a cavity seated above the last named ex-
 pansions, when its contents have been com-
 pletely evacuated.  It is hardly necessary to
 point out how far these facts tend to explain
 the frequent degeneration of large abscesses
 into  fistulous cavities; we  will merely
 impress  on the reader these obvious de-
 ductions, fully borne  out by clinical ob-
 servation ; 1st. that fistula in ano arising
 solely from this difficulty of collapse, sel-
 dom extends above the internal sphincter
 muscle, except perhaps in those rare cases
 of stercoraceous abscess caused by the es-
 cape of foreign matters from the rectum,
 at a considerable distance from the anus;
 and 2d.  that the simple enlargement  of
 the external orifice of an abscess,  once
 threatening to form a  fistula, by no means
 secures the prompt and entire obliteration
 of the cavity.
   The second mode in which abscess may
 give rise to  fistula is by the protracted
 lodgment of pus.  This is often under the
 complete command  of the surgeon—as it
 is less directly dependent  on the anato-
 mical  structure of the region.   When an
 abscess is  spontaneously  evacuated, the
 orifice is almost always small and ineffi-
 cient,  except in  the gangrenous variety.
 The pus, instead of flowing out with free-
 dom, is partially retained, and opposes a
 mechanical impediment to the collapse  or
 obliteration  of the  cavity: altered  and
 vitiated by the contact of the air, it  soon
 becomes extremely irritating,  and  pro-
 duces  additional adhesions and induration
 in the surrounding tissue, until the affec-
 tion assumes the fistulous character. When
 the depot is large, the  existence of partial
 septa may keep up the suppuration in the
 deeper-seated parts, and thus prevent the
 closure of the orifice. When the presence
of such septa is neglected by the operator,
no enlargement of the outlet can possibly
remedy the evil. In fistula following those 
ANUS. (Fistula.)                            133
unhappy  cases of abscess which are the
remote consequence of intractable consti-
tutional diseases, such as  phthisis,  scro-
fula, syphilis, cancer, &c.,' surgery, as an
art, is of little avail in effecting a perma-
nent  cure, which, if at all possible, must
depend upon remedies addressed to the
more pervading disease.  It should not be
forgotten, however, that fistula in ano may
coexist with these affections, without de-
pending on them, and that there is strong
reason to believe that even when the con-
nexion  is  more immediate, it is  not the
general disease, but some local symptom,
that  gives rise  to the fistula.  Thus, in
 phthisis, it may result from the ulcerations
 of the  mucous  membrane commonly at-
 tendant  on that disease, when they are
 accidentally  seated  near,  or  within the
 anus (Bayle, Ribes.  Mem.  de  la Soc.
 d'Emul. X. 114.); in scrofula, from  in-
 flammation of a lymphatic gland  ; in  sy-
 philis, from  chancre  within  the  verge.
 We  shall have  occasion to allude to. this
 subject hereafter.  When abscess of the
 anus arises from caries of the spine, or
 any  other organic change of  a  durable
 character in distant parts, it must degene-
 rate, almost  of necessity, into a fistula
 which cannot be cured, even by an opera-
 tion, until the remote cause  is removed,
 and the  supply of pus prevented.   There
 may be an exception to this rule in a case
 admitting of a counter-opening, by means
 of which  the pus may be diverted from
 the pelvis.
   But there is still another mode in which
 the retention of pus in an abscess gives
 rise  to fistula, a mode more generally ob-
 served than all those above enumerated;
 and this is by mechanical distension. The
 spontaneous  orifice of an abscess often
 contracts  after it is formed, to such a de-
 gree that it scarcely permits the egress
 of the pus in sufficient quantity to unbur-
 den the cavity of the daily secretion; and
 it remains at all times liable to  absolute
 closure, by swelling from temporary in-
 flammation,  the arrest of small  portions
 of hardened pus, the formation of an ac-
 cidental  valve  of cellular tissue at the
 opening, by pressure on  the part,  or by
 simple changes of position, &c.   As none
 of these  causes are very permanent in
 their action, the cavity is alternately dis-
 tended and relaxed, and nature continues
 her endeavours to contract the dimensions
 of the depdt, while  some part of its pari-
 etes is continually compelled  to  yield to
 the  occasional  distensions.   The conse-
 quence is that the weaker portion yield?,
 and the abscess travels slowly in the di-
   VOL. 11.          12
rection of the least resistance, while the
induration by which  it is surrounded is
continually increasing. When the abscess
is of- the phlegmonous character, and the
intestine is denuded,  it naturally tends in
this  direction, and the resulting fistula is
located  in  the immediate vicinity of the
rectum, and may ascend to  almost any
distance along  its surface,  or  even  be-
tween its coats; but these coats very sel-
dom yield to eccentric absorption.  If the
abscess is  of the tuberculous or hemor-
rhoidal  character, it naturally makes its
way inward, immediately  beneath the mu-
cous  membrane,  and outward, between
the skin and superficial  fascia, assuming
the form of true fistula, in that portion of
its course  which  lies below  the  inferior
margin of  the  internal sphincter,  but
spreading out and denuding the intestine,
above that spot  We have  now under
treatment  a case  of fistula in ano, origin-
ating chiefly in this manner, from so slight
a cause as the inflammation of a sebaceous
folllcb on  the  perineum, near the scro-
tum, two and a half inches from the anus.
The  opening of the little abscess which
it occasioned, being insufficient for its
evacuation,  the pus gradually formed  a
fistulous canal reaching  immediately be-
neath the skin,  to within  less than half an
inch of the margin of the anus.  A coun-
ter-opening was made at  this spot, by an-
other practitioner, and a  ligature was in-
troduced, with  the intention of dividing
the  parts by ulceration!  A great degree
 of inflammation and consequent indura-
 tion  resulted from this  treatment.   The
 seton was removed,  and the sinus laid
 open in the usual manner,  by a  surgical
 friend, but  even this did not  arrest the
 inarch of the fistula; at the conclusion of
 the operation there was  ascertained to be
 no prolongation of the canal beyond the
 limit of the incision, but  the extremity of
 the cut next the anus could not be healed.
 This part being  somewhat  irritated  and  (
 occasionally stretched in consequence of
 the presence of several large excrescences
 in the neighbourhood, and the discharge
 of pus being occasionally arrested by the
 position of the patient, the fistula was very
 gradually  reproduced, and extended after
 a few weeks as high as the middle region
 of the  anus, following the duplicature of
 one of the  radiated  folds of integument.
 The point of a small probe introduced into
 the sinus, could then be felt most distinctly
 beneath the lining membrane of the anus,
 but no communication with the intestine
 yet exists, although the very narrow canal
 has now expanded itself  into a broad sac, 
134
ANUS. (Fistula.)
above the margin of the internal sphinc-
ter.  As this extremely simple case has
now resisted for months all proper  mea-
sures of local treatment and regimen, the
operation  will be repeated, and the ex-
crescences removed,  on the first  conve-
nient opportunity;  the extreme nervous
irritability of the patient's constitution at
the time,  having prevented the last  men-
tioned step, on the former occasion.
  When a tuberculous abscess opens spon-
taneously  into  the  middle region of the
anus, the  escape of the discharge is ren-
dered difficult by the constriction of the
sphincters both above and below the  spot;
it consequently makes its way with ra-
pidity toward the perineum, and becomes
almost immediately obvious to the sur-
geon.  It should never be  suffered to be-
come chronic or fistulous. (See $ 12.)
   We have already spoken of the manner
in which  deeper-seated abscesses, when
neglected after their evacuation, approach
and denude the rectum, becoming fistulous
in  their progress;  the route which the
fistula may ultimately pursue in its course
to the surface, though dependent in  some
degree  upon anatomical position,  is very
various and irregular; sometimes angular,
or extremely tortuous. It appears to us, that
among those fistulae which arise from local
causes in the neighbourhood of the  anus,
such as branch, or give rise to productions
running in different directions toward the
deeper-seated parts of the pelvis, owe the
permanence of these profound  extensions
to  the  arrest  of the discharge,  by the
operation of mechanical causes,  rather
than to the pathological condition of the
tissue in which they are seated; and  when
sufficient external  openings are made  to
secure the free and continued  evacuation
of such canals, we cannot perceive the
necessity of laying them  open seriatim,
as advised by the warm advocates of the
knife, particularly when they are in close
proximity to the  rectum.   We shall have
occasion  to allude to this question again,
when speaking of the treatment.  A  great
many of the causes of fistula, enumerated
by authors, being in reality only causes of
its almost universal precursor,—abscess,—
we must refer to the preceding section for a
more detailed account of them. Those cases
said to occur sometimes spontaneously, of
 which the patient himself is unconscious
 untd they are far advanced, are probably
 the consequence of very small tuberculous
 abscesses, like that above recorded.
   Although we  cannot subscribe to the
 opinion of Percival Pott, that the de-
 generation of abscess into fistula, after
proper incisions have been made,  is al-
ways attributable to malpractice, there is
no doubt that improper stimulating appli-
cations  to the wound may yet be ranked
among the causes of this affection.  The
remarks of Marchand,  upon the influ-
ence  of dressings which impede the dis-
charge  by their mechanical  action,  are
also deserving of attention. (See Biblio-
graphy of J 12.)
  The concussions occasioned by efforts in
leaping, riding, &c., acting as they do
upon  the whole amount of* blood in  the
portal system, which  is  unsupported by
venous  valves, often produce  injuries of
the vessels and embarrassment of the cir-
culation about the anus, and are therefore
an  important remote cause of fistula in
ano. Hence the remark of Heister (Inst.
Chir. Cap. clxviii. 4.), that the disease is
very  common  among  troopers,  and  the
universal observation that it is one of the
peculiar evils  attendant  on the practice
of medicine in country situations.
  2. Varieties.  When a fistula has com-
munication both externally, on the integu-
ments,  and  internally,  into the  anus  or
rectum, it is termed complete fistula;  but
when it opens only onto the surface, or
into  the  canal, it  is  called  incomplete.
When,  in the latter case, there  exists no
communication with the  intestine,  it re-
ceives the name of  external blind fistula,
and when there is no superficial outlet, it
is denominated internal  blind,  or  occult
fistula.
  Some authors are said to deny the  ex-
istence of external  blind fistula,  believing
that there is  invariably an internal open-
ing, even when, in consequence of the
small dimensions of the passage, it cannot
be  detected by the probe. (Foubert,  Sa-
batier, Larrey.)  We  have carefully ex-
amined these  authorities, and  find that
although they endeavour  to establish  the
ffreat frequency of  complete fistula, their
language scarcely appears to bear out the
rigorous interpretation put upon it by other
writers. (Boyer, Velpeau.)  Be this as it
may, it is now impossible to doubt the oc-
currence of such sinuses, in  the face of
all the evidence from the days of the Hip-
pocratic physicians, to the present time.
The  authority of Mr. Pott  alone  would
almost  suffice to determine the point in-
dependently of the positive proofs obtained
by Boyer, from post-mortem examination.
(Mai. Chir.  X. 109.) There is nothing in
the anatomical or physiological character
of  the part  which can in any manner ren-
der it  exempt from an affection, common
 in  all places near the  surface, where free 
AIM US. (Fistula.)                            135
cellular tissue is somewhat plentiful.  The
position of Larrey, that all complete fistu-
la?,  except such as result from wounds,
advance from within  outwardly,  is  alto-
gether untenable (Memoires.  II. 372.);
even when the  abscess which gives birth
to the fistula is occasioned by an ulcera-
tion or the presence of a  foreign body in
the rectum, it does not necessarily become
complete or stercoraceous; for it is well
known that such accidents give rise to ad-
hesions in the surrounding parts, and that
a submucous abscess may be  produced by
the inflammation of  contiguous  tissues,
without destroying those adhesions.   The
great comparative frequency of complete
fistula cannot be denied;  but this is rea-
dily explained by the  fact that consider-
able denudation of the intestine is so com-
monly attendant on abscess of the  anus,
and that this denudation  is generally lo-
cated where there is great danger of dis-
ruption of the unsupported parietes during
defecation.
  The existence of occult fistula has also
been  denied, and with more  appearance
of reason; for when the  primary abscess
is seated in or above the levator ani  mus-
cle, the orifice is dependent and the diffi-
culty of closing the cavity does not  exist
in full force; as has been stated in the
last and the beginning of the present sec-
tion ;  and  when it occurs immediately be-
neath the lining membrane  of the  anal
canal, it almost always effects an external
opening  in  a short time. Vet there is
ample proof that such abscesses sometimes
become chronic;  enduring  indefinitely,
when neglected by the surgeon, and con-
tinuing to discharge  their contents into
the canal.  They are reduced, says  Vel-
peau, to the condition of cavernous ulcers,
but the discussion in relation to their ex-
istence has become a dispute  about words.
(Diet, de Med.  III.  318.)
  In  regard to their  form  and number,
fistulae in ano differ materially. We often
observe one on each side,  in the same pa-
tient ; not unfrequently, there are several
external sinuses, all  converging toward
one intestinal orifice; much  more rarely,
there are  several communications  with
the rectum or anus, and sometimes the in-
ternal and  external orifice  of a simple
fistula, are found on opposite  sides of the
mesial plane. Of the  indefinite cavernous
extensions with which the case  is occa-
sionally complicated,  we have  already
spoken.
  3.  The seat  of the  internal orifice of
fistula in ano, has been much debated of
late, and the question is one of too much
practical importance to be passed without
notice.  The various plans of operating,
and the form of the instruments employed
for the cure of this disease, from the ear-
liest times, clearly show that the commu-
nication has been supposed to take place
in many cases, at a considerable distance
from the anus, and sometimes so high as
to be beyond the reach of the finger. The
language of Sabatier, hi his work on ope-
rative  medicine,  leads to the  inference
that he considered the most frequent causes
of fistula to be such as  produce perfora-
tions in the anal canal; his  pupil, Ribes,
attributes to him opinions  still  more ex-
clusive, and adds the result of eighty ob-
servations confirming the position that the
internal orifice is almost invariably dis-
covered very near the  anus, being  gene-
rally visible externally, on careful exam-
ination, and  never more than five  or six
lines above the junction of the skin with
the mucous  membrane.  (Loc. Cit. 135.)
He admits that ulcerations seated in the
lower extremity of the  rectum, are among
the causes  of fistula, but denies  that they
produce  such consequences when  more
distant from the outlet (lb. 115.) Yet it is
somewhat singular that this writer should
include among the cases which Sabatier
and himself considered as past the aid of
surgery, admitting no  other treatment
than careful attention to cleanliness," those
of which the internal orifice is placed be-
yond the reach of the finger."  (lb. 139.)
Larrey declares  in  equally  strong lan-
guage that the seat of  the internal orifice
is always between the sphincters, in the
middle  region  of the anus or below that
place. (Memoires.  II. 373.)  Velpeau has
observed thirty-five cases with  the view
of determining this point.   In   four in-
stances, the  orifices were found  from the
height of one and a half, to that of two
and a  half inches, " consequently a little
above the external sphincter,"  says this
author; but if we judge from the ordinary
dimensions of the anus, all these  openings
must have been above  the  margin of the
internal sphincter,  and some  of  them,
nearly as high  as  the upper extremity of
the canal.  In a fifth case, the orifice was
elevated more than three inches, and  the
finger  reached  it  with  difficulty.   The
others opened very near the lower end of
the canal, three of them being seated be-
low the external sphincter,  or almost ex-
ternally. It is stated that Richerand sub-
scribes to the opinions  of Ribes; and the
honour  of having been the first  to propa-
gate them  is claimed, by Pleindoux, for
Brunel, a physician of Avignon, who ad- 
136
ANUS. (Fistula.)
vanced them in 1783. (Ephemer. de Mont-
pellier. VIII. 210.)  On the other hand,
the frequent occurrence of fistulous com-
munication with the rectum, far above the
anus, and sometimes beyond the reach of
the finger, is asserted  by nearly all the
authorities, from the earliest times, down
to those of Dessault.  It is now univer-
sally conceded, if indeed it ever was denied
(see Heister.  Inst. Chir.  Cap. clxviii.),
that the orifice is seated, in a vast majority
of instances, within the anal canal; com-
monly in its middle  region,  often in its
superior part, and not unfrequently in its
lower portion (see Art. I.). Yet it is not less
true that occasional cases of much greater
elevation of the orifice have occurred to most
modern surgeons.  We do not recollect to
have met with any exception among Eng-
lish authorities; and we  may add to the
high testimony of Roux  and Boyer in
favour of this position, that of all the dis-
tinguished American surgeons with whom
we have conversed.
   The very great frequency of mechan-
ical injuries resulting from the action of
faeces and extraneous  substances on the
mucous lacunae  and wrinkles of the upper
region, and on the parietes of the middle
region,  the  ulceration of  hemorrhoidal
veins, so strongly  insisted on by M. Ribes,
the inflammation  sometimes  produced by
similar causes in the preternatural pouches
of Dr.  Physick, when they are present
and  perhaps in the sacculi,  of Horner,
when diseased,  are quite  sufficient to ac-
count for the fact  that in  a great majority
of cases, the orifice is found to be situated
as several of the  authors quoted have de-
scribed, and the practical inferences which
they have drawn  from this  fact are cer-
tainly highly valuable. The enlarged form
of the great pouch of the  rectum, the flex-
 ibility  of its  occasional  transverse folds,
and the comparatively slight tendency of
the faecal matters to escape, when the pa-
rietes of the intestine are ruptured above
the commencement of the anus, explain,
 not less satisfactorily, the rare occurrence
of fistula with  an opening  more deeply
 seated.
   Ribes and Larrey narrate some most
 interesting cases, of gun-shot wounds in
 which balls have penetrated the rectum
 and have been  afterwards discharged per
 anum without  producing fistula; and in
one  of these, -observed by the former,  a
portion of the dress, carried in by the ball,
but lodged exterior to the intestine, gave
 rise  to abscess of the  anus and was dis-
 charged with the  pus;  yet the depot  did
 not at any  time  communicate with  the
canal.   Notwithstanding this fact, there
is  sufficient  evidence to show that the
rectum  may be penetrated at any height,
either by foreign bodies or ulceration from
within,  or by the destruction of its walls
in the progress of abscesses from without.
The occasional existence  of  strictures, or
of partial mucous septa  in the intestine,
must necessarily increase its liability t>>
such accidents. (See  Rectum.)
   The depth and extent of the sinus have
no fixed relation to that of the  interna!
orifice of the fistula, for  a probe  may be
sometimes passed with the utmost facility
for many inches, either between the coats
of the rectum or in other directions, while
the communication with the  anus is close
to the extremity of the canal-.  Larrey
ventures  to attribute the  cases in which
the orifice is more deeply seated, to the
unintentional puncture of the intestine by
the probe, in search ot that which has no
previous existence; and the facility with
which the blunt bistoury often enters the
rectum, in the operation of Pott for in-
complete external fistula, proves that such
an accident  might easily occur to a care-
less surgeon.
   4. Diagnosis.   External fistula in ano,
whether  complete  or incomplete, is not
always detected without careful examina-
tion.   When it is larjje,  and surrounded
by extensive induration, it is easily recog-
nized ;  if it  is preceded by an abscess of
considerable size, the nature of the com-
plaint cannot be mistaken;  but when its
dimensions  are small, and when,  as often
happens, it has continued for some time
before  it attracts attention, the orifice is
occasionally hidden between the radiated
folds of the  margin,  or  lies  concealed at
the bottom of a little follicular depression;
not unfrequently it is covered by a slight
crust or  scab, and it may  even become
regularly cicatrized  from time   to time
until the accumulation of pus in the sinus
a^ain forces an outlet.  The patient com-
plains that  his linen  is continually soiled
by a discharge wh'ch he often attributes
to hemorrhoids:  the  stain  is sometimes
sanguineous,  more frequently sero-puru-
lent,  generally  serous  or  mucous, and
rarely presents the characters of true pus.
It is often very fetid, and sometimes min-
gled with stercoraceous matter.  By strict
attention the situation of the external ori-
fice may always be discovered, though  i'
 is sometimes extremely minute.  On the
 introduction of a  probe,  the  instrument
usually takes a  direction at first toward
the anus, and then upward along the rec-
tum, but this is not invariably the case. 
AIM US. (Fistula.)                            137
Those instances of fistula which extend
toward the recto-ischial excavation, or to-
ward the nates or perineum, without ever
approaching the intestine, differ in no re-
spect from similar affections of other parts,
and  should be treated in a similar man-
ner (see Art. Fistula); but besides these
there are  some, so angular or tortuous that
they travel in the first instance in a course
very different from that by which they ul-
timately approach the  canal; and  others,
which  mount  almost directly  upward
through the sphincter externus, or beyond
its edge.   In most cases,  the route of the
probe may be readily traced by the finger
when introduced into the  rectum,   the
point being felt, at first,  immediately be-
neath the integuments  of the middle and
lower portions of the anal canal, and af-
terwards  ascending to the height of one,
two, three or more  inches along the rec-
tum, until it reaches the extremity of the
cul-de-sac formed by the denudation of the
intestine.  Sometimes  it is  only the mu-
cous membrane that intervenes between
the  probe and the finger; sometimes the
instrument passes outside of the internal
sphincter, or through  its substance,  and
the  septum  includes all  the coats of the
rectum.  In the cases in which the fistula
penetrates, or,lies  beyond  the  external
sphincter, it is sometimes separated to a
 considerable distance from the intestine,
 and the septum may be so indurated that
 the probe is obscurely felt.
   It is often much more difficult to deter-
 mine the difference between  a  complete
 and an external blind fistula.  If portions
 of solid fecal matter, ascarides, or foreign
 bodies, are from  time  to time evacuated
 from the  sinus, the case is indeed obvious,
 and the escape of wind, by the same route,
 is scarcely  less conclusive; but  a  dark
 colour and stercoraceous  odour of the dis-
 charge, are not a sufficient proof of the
 existence of an internal orifice,  for  rea-
 sons already noticed in the preceding sec-
 tion ; neither does the absence of all these
 appearances furnish positive  evidence of
 its nonexistence.  Even exploration by the
 probe does not always determine the point,
 for  the sinus may branch or may be con-
 nected with cavities extending- in various
 directions; its course  may be 60 tortuous
 that it cannot be thoroughly traced, or it
 may be interrupted  by partial septa which
arrest the instrument.  Still this mode of
 investigation will generally succeed, if
the  fistula is complete, and  if due atten-
tion is paid  to the fact that the  internal
orifice is almost always near the extremity
of the anus.  It is proper to carry the in-
                  12*
strument in the first instance  directly to-
ward the margin, if there  is any vacuity
in this direction;  and having fully ascer-
tained that the outlet is not situated in the
lower portion of the canal, the surgeon
should introduce an index finger into the
anus, and continue his search by causing
the  point of the probe to traverse all the
denuded portion of the parietes of the
middle  region  between  the  sphincters,
where it will be felt with  the utmost dis-
tinctness if the fistula has taken this route.
It must be lx>rne  in mind, however, that
even when  the instrument  has entered
the  canal,  it may  not always come into
contact with the finger without consider-
able manipulation, because the point  may
still be covered by the smooth  walls of the
sacculi of Horner, or the  mucous lacunse
of the part.
   For thus  much  of  the  examination, a
small blunt silver probe is better than any
other, but it must be suffered to  enter
without force, or, as if spontaneously, for
slight pressure is sufficient to break down
the  very delicate  cellular  connexions be-
tween the integuments  and the parts be-
neath ;  and  even  the former sometimes
yield very readily.
   Having  ascertained as clearly as possi-
ble that the  orifice is not seated below the
margin of the internal sphincter,  the sur-
geon should examine with great care, the
parietes of  the  superior  portion  of the
anus and  the neighbouring  parts of the
rectum, before attempting to  trace any
farther the course of the sinus.   In many
 instances a little papillary eminence points
out the site of the opening, and even when
 this does not happen, the unusual  sensi-
 bility of a particular point leads to a pro-
 bable conjecture  as  to its  location.  In
 either case,  a valuable guide is obtained
for  the  direction  of  instrumental re-
 searches.  In exploring deep  sinuses, it is
 often, perhaps always, advisable to employ
 a delicate,  flexible  probe;  particularly
 when the  fistula extends beyond the reach
 of the finger.  Much care is required in
 this operation, and it may even be doubted
 whether we  should seek at all for the in-
 ternal  orifice in  such cases, unless the
 positively  stercoraceous character of the
 discharge  undeniably determines its pre-
 sence : this  question will be argued here-
 after.  When changes of  direction in the
 superficial  portions of the sinuses inter-
 fere with  the  proper exploration,  such
 parts should be laid open  by the bistoury,
 without hesitation.
   If no orifice can be detected by means
of the probe, it has  been advised,  from 
138                            ANUS.  (Fistula.)
early times, that tepid injections of water
or mild, coloured fluids should be injected
into the fistula; the return of which, by
the anus, is a decisive proof of  its com-
pleteness.  This plan may be advisable in
certain cases; but there is little gained
by the discovery of the existence  of an in-
testinal orifice, unless its location is like-
wise ascertained.
   External  fistula,  once  discovered,  is
little likely  to be confused with any other
affection,  except,   perhaps,  the  urinary
fistula, which sometimes opens near the
anus, and may even cause denudation of
the rectum.   In the last case, the obvi-
ously urinous smell of the discharges, so
strongly  diagnostic of the latter  disease,
may be obscured  by the transfusion of a
stercoraceous odour; but the flow of urine
from the outlet, during the act of evacu-
ating the bladder,  furnishes all  the  evi-
dence  required to distinguish it from the
former.
  The diagnoses of occult fistula  is some-
what more  difficult •  The symptoms of
the abscess  in which it  generally origin-
ates, having subsided (see § 13.), there re-
main a slight degree of soreness,  and a
purulent discharge  from the  anus,  which
coats the faeces in their passage.  The pa-
tient attributes these  symptoms  to inter-
nal piles, and seldom consults the  surgeon
until the disease has  continued for a long
time. If the practitioner is contented with
a careless examination,  as happens but
too frequently in anal disease, the pain
and the discharge  may be considered as
the result of ulceration  in the  rectum,
blenorrhagia, hemorrhoids, &c. The pre-
vious history of the case may prevent such
mistakes when the fistula has been occa-
sioned  by a considerable abscess;  but it
may also occur from follicular ulceration,
disease of the sacculi of Horner, or in-
flammation of the  preternatural  pouches
of Physick,  without those severe local and
sympathetic inconveniences that charac-
terize  abscess  pointing  internally.   Re-
ferring the reader to other heads for many
remarks on  this subject we will merely
mention that occult fistula  almost always
produces changes obvious externally. Con>
monly there  is a distinct hardness  or small
tumour at the margin of the  anus; not
unfrequently there  is some softening in
the centre of th's hardness, with  a red or
livid spot, beneath which, the integuments
may or may not be thinned by ulceration;
and, if pressure be made on this  tumour,
an increased discharge of pus takes place
from the anus.  These signs can hardly
be presented, if true occult fistula is seated
in or above the levator ani muscle, as M.
Velpeav supposes sometimes to happen.
The  finger,  introduced into  the rectum,
often perceives the location of the orifice,
as in complete fistula;  but the most posi-
tive evidence is obtained by means of the
bent  probe  of Dionis and Heister, em-
ployed as directed in $  12.
   5.  Prognosis. The prognosis of simple
fistula in ano is almost always favourable.
The principal exception to this rule is  in
the case of complete stercoraceous fistula,
when the intestinal orifice cannot be de-
tected or obliterated, for the constant pas-
sage of fecal matter then removes all pos-
sibility of cure. Another exception is made
by most writers, with regard to those sim-
ple fistulae which penetrate  the  perineal
and pelvic aponeuroses, and are connected
with extensive cavities passing in various
directions toward the deeper part3 of the
pelvis.  That some such cases may be in-
curable  in  their nature,  there  is little
doubt; but whenever it  is possible to make
and preserve a free outlet for the purpose,
the powers  of nature are  never inactive
in limiting the extent of the disease. The
adventitious  mucous  membrane which
forms the lining of all fistulae, (the exist-
ence  of which, discovered by John Hun-
ter,  is now no  longer doubtful,) has  a
constant tendency to contraction, and it  is
not unusual to see  the  extent of old and
considerable  sinuses greatly  diminished
by this means, even when very little as-
sistance is rendered by the surgeon. That
the extent  of the  suppurating cavity  is
not an insuperable bar to recovery from
this disease,  is most clearly shown by the
fact that cures have been effected, in cases
of psoas abscess connected with fistula in
ano.  We have already quoted  a.n  instance
of this kind  from the late Professor Dor-
set.   It  should not be forgotten  that the
parts  above  the deeper-seated fascia, are
precisely those in which there is the least
mechanical  resistance to the  approxima-
tion of the sides of the cavity under ab-
dominal pressure.
  Though a vast majority of cases con-
tinue during life, unless the aid of surgery
is invoked,  it  is no longer questionable
that  fistula  in ano, when not stercora-
ceous, may recover spontaneously. Many
cases  of this kind have  been noted by dif-
ferent writers; suffice it here  to  mention
the names of Pott, Ribes, and Velpeau,
as among the number.  They have yielded
t> country air and exercise, and to such a
regimen  as  is  calculated to  induce em-
bonpoint  These exceptions to a genera!
law have, however, but  little value except 
ANUS. (Fistula.)                            139
to prove the importance  of regimen as a
coadjuvant in the treatment of the disease.
   On the subject of the prognosis, in fistula
in ano  complicated with other local or
general affections,  such as  caries  of the
spine, scrofulous abscess, cancer, syphilis,
phthisis, &c,  little need be  added to the
remarks already made under the head of
causes.   When the fistula proceeds from
either of these complaints,  it  is obvious
that  the  former  cannot be  eradicated
until the latter is cured ; it is then reduced
to the condition of simple fistula;  hence,
when the  primary affection  is  incurable,
so likewise  must  be  its  consequence.
We may add  a few words on the subject
of the  connexion between   phthisis and
fistula.  There is an opinion  very popular
both in  and out of the profession, that it is
wrong  to attempt the cure  of the latter
disease  in persons who are predisposed to
consumption; but the researches of Laen-
nec and Bayle do not support the position.
MM. Roche and Sanson have ventured to
assert that the belief in the connexion be-
tween  these  complaints is  now  almost
abandoned, but this is scarcely warranta-
ble. M. Ribes has come  to the conclusion
that fistula is associated with phthisis in
two different ways, firstly, as a  contempo-
raneous,  but   independent   accident,  in
which case the prognosis is not less  fa-
vourable than  when there exists no com-
plication ; and secondly, as a consequence
of one  of the  sympathetic  symptoms  of
this  disease,  namely, ulceration  of the
mucous membranes, which are sometimes
seated near the anus.  Under the latter cir-
cumstances the permanent cure can hardly
be expected.   M. Velpeau  remarks that
the attempt at cure  is not productive of
injury,  in consumptive patients, but that
success is  almost always impossible:  the
wound  continues soft and pale, and the
suppuration intractable.
  6. Treatment.   The plans of general
treatment required in fistula in ano  are so
various, and so completely dependent upon
constitutional  peculiarities, or  accidental
complications of the disease, that it  would
be useless to discuss them here.  They all
tend to effect  the same purpose, namely,
the restoration of general health, vigour,
and embonpoint, and must be  conducted
on well-known principles, according to the
condition of each particular patient.  The
object of all local treatment  is the oblite-
ration  of the  abnormal  cavity; but  the
modes recommended  by different writers
for accomplishing it, are so numerous that
the mere analysis  of them  is  a task  of
difficulty.   It is not our design to make a
vain display of learning by enumerating
all the measures formerly in vogue, and
we shall  confine ourselves to the consi-
deration of such as are still in use, either
in their original, or  in a modified form;
referring the curious reader to the Biblio-
graphy of this section, for information of
a purely historical character. Our remarks
on the several operations and instruments
will be preceded by some general observa-
tions  on the causes  of difficulty in the
cure,  and the means of overcoming them.
   a. The forces which oppose the oblite-
ration of a fistula in ano, when free from
complication, are four in number.   Two
of these are mechanical; 1st. the changes
in the relation between contiguous parts
in the immediate neighbourhood of the
anus,  produced by the habitual tonic con-
traction of the sphincters, their frequent
dilatation, the descent of the superior por-
tion  of the canal  in  defecation; the un-
yielding character of the bony walls of the
pelvis; and the effectual resistance offered
to the descent of the  viscera under abdo-
minal pressure, by the levatores ani mus-
cles and the pelvic and perineal aponeu-
roses :  2d. the permanent lodgment of pus
in the sinus, occasioned either by the ex-
istence of partial septa and great inequali-
ties of surface, or by the insufficient di-
mensions  of the external orifice:  a 3d
force  is purely physiological, and consists
in the peculiar vital condition of the pa-
rietes of the sinus, which are sometimes
covered with unhealthy fungoid granula-
tions, as remarked by  Mr. Pott, and more
frequently converted into the  pseudo-mu-
cous membrane of which we have already
spoken; both these changes of structure
are insuperable bars  to the formation of
secure adhesions:  the 4th force  is pecu-
liar to the true stercoraceous fistula, and
consists in the frequent passage of intes-
tinal secretions and excrementitious mat-
ter through its canal.   The action of this
cause  is of a mixed  character.   It not
only occasions frequent mechanical dis-
tension of the sinus, but lessens its natural
tendency  to contraction;  for it is  found
that fistulis or sinuous ulcers  communi-
cating with secretory or excretory ducts
generally continue less manageable than
those which have no such connexion, even
after the  natural route of the discharges
is  fully re-established—hence  one of the
great difficulties of curing salivary fistula.
  With regard to the first of these causes,
it is well known that when the contact of
the parietes of a truly fistulous cavity is
mechanically prevented, nature makes no
effort  towards its obliteration by granula- 
140                            ANUS. (Fistula.)
tions, unless the character of the  acci-
dental  membrane  lining  the  sinus is
changed  by surgical  measures.   This
change  may be accomplished either by
stimulating  and caustic injections, or by
laying open the canal, so as to convert it
into a simple suppurating wound.  If the
former means be employed in the disease
of which we are now treating, there  is no
method  by which we can effectually con-
trol the action  of the muscles,  and the
consequent separation of the walls of the
cavity, at least  in  some part of their ex-
tent ;  the pseudo-mucous membrane is al^
most always reproduced, the disease con-
tinues,  and  is not unfrequently rendered
more  important by the  loss of substance
occasioned by the treatment. But  in those
parts of the track of a fistula in ano where
no tendency to separation exists, this mode
of treatment may be beneficial in certain
cases: it  is  therefore important to deter-
mine what parts are thus exempted.  We
have  already stated the opinion  that all
cavities  seated  above or within the leva-
tores ani muscles are closed by abdominal
pressure,  when  completely  evacuated.
There is  little  reason to anticipate  diffi-
culty in the  approximation of the parietes,
even in  sinuses lying between these mus-
cles  and  the middle  fascia of the peri-
neum ; for the contraction of the levators,
which alone could terjd to produce a sepa-
ration,  scarce  ever takes  place  except
during defecation, when the sphincter ex-
ternus is proportionably dilated, and when
the abdominal pressure  is greatest.  (See
Art. II.)  The  same cause  is equally effi-
cient in favouring the contraction of cavi-
ties seated in the meso-rectum, or between
the sacrum  and the intestine; and when
the mucous  coat or the entire walls of the
latter are denuded, at any point above the
superior extremity of the anal canal, the
perfect flexibility of the membranes,  and
the mobility of the adjacent organs, pre-
clude the possibility of any vacuity  from
changes of  relation among the parts in
consequence of muscular action.  If these
physiological views are  correct, difficulty
in the treatment arising from the cause
under discussion, can only occur in the in-
terval between  the two sphincters, and in
the recto-ischial excavation.  It follows
then, that granting the occasional propri-
ety of injections to produce adhesion in
those sinuses or excavations which pene-
trate  beyond the fascia media, they are
not dependable  in the treatment of fistulae
or parts of fistulae which are situated more
superficially.
  We  have dwelt at  sufficient length
upon the second-named force  which op-
poses the obliteration, when speaking of
causes;  but  the third  demands  some
farther  comment.  The same  vital iaws
which cause the formation of the pseudo-
mucous  membrane of a  fistula  and the
suppurating tunic of an abscess, whenever
their presence is  required, as certainly in-
sure their destruction  after the cessation
of their functions. Both these novel forma-
tions have a strong tendency to contrac-
tion,  and both,  having once  completed
their duties, are speedily  reduced to com-
mon cellular or cellulo-fibrous tissue. The
latter is, however, an active  agent  in the
process of granulation, and cannot be made
to disappear, until  that process is  com-
pleted by the formation of a cicatrix: the
former,  on the contrary,  is already cica-
trized ;  it is a portion of spurious internal
integument, differing in no essential man-
ner from an  excretory duct; it is always
the passive conduit of some secretion, and
must disappear when no longer  employed.
Unfortunately the mucous discharge from
the membrane which lines the canal is often
sufficient of itself to secure its perpetuity.
  Now, in extensive fistula in ano, unless
when very long continued,  the deeper-
seated parts are generally  in the condition
of an open abscess or cavernous ulcer, ca-
pable of contracting by granulation, and
equally liable to assume the fungous char-
acter described by Pott.   It is needless
here to  state how easily  parts in such  a
condition may be modified and  benefited
by  local applications.  (See Ulcer.)   The
more superficial portion of the sinus, on
the contrary,  is generally lined with pseu-
do-mucous membrane;  and as it is almost
impossible to arrest  entirely the passage
of the discharges, it  follows that even if
the mechanical causes which oppose the
cure were absent, the success of any local
applications would be  very doubtful; but
when it is considered that all these causes
act together, and with peculiar force upon
the lower portion of the sinus,  there can
be  no difficulty in understanding the fact
that the only certainly effectual mode of
curing the disease is the complete division
of the parietes in  at least so much of their
extent as lies below the superior margin
of the external sphincter.  The  occasional
though  very  rare occurrence  of sponta-
neous cures, the very strong testimony of
Pott, and the numerous  cures  of exten-
sive fistula? by Sabatier,  Ribes, Larrey,
Lawrence,  Syme, &c,  when incisions
have been carried no higher  than the
point indicated, although the denudation
of the rectum had taken place  to a great 
ANUS. (Fistula.)
141
 extent are sufficient to place beyond dis-
 pute the position we  have been  endea-
 vouring to prove, and explain, that the dif-
 ficulties which oppose the cure of fistula
 in ano without  an  operation are mainly
 confined  to the  lower part of the  sinus,
 and hence, that  the  long incisions of the
 rectum still  so  frequently recommended
 and practised, as well  in  external as in
 complete fistula, are of very doubtful ne-
 cessity.
   Those cases in which there are, at the
 same time, an extensive denudation of the
 rectum, and  irregular and deep-seated  si-
 nuses which  retain a portion of the pus,
 form only an apparent exception to this
 law; for the division of the  parietes of the
 anus alone, is amply sufficient for the eva-
 cuation of such  discharges as can be  ef-
 fected  by any  surgical  measure  of the
 kind.   It  is  right,  under  these  circum-
 stances, to divide all partial septa within
 reach of the  knife,  but the extension  of
 the opening  in the walls of the rectum
 can have no beneficial  effect.
   A true stercoraceous fistula, with an  in-
 ternal orifice  placed high up in the canal,
 is indeed an exception, and for obvious
 reasons.  Nothing short of a complete  di-
 vision of the sinus from the  internal  to
 the external  orifice  can be depended  on
 for the cure  of stercoraceous fistula; but
 the cases are  rare in which the communi-
 cation with the rectum is located far above
 the anus, and those in which a communi-
 cation so placed gives admission to sterco-
 raceous matter  are  still more rare.   The
 mere  fact  of a fistula being  complete,
 when it is not traversed by intestinal mat-
 ters, is not in itself a sufficient reason  for
 carrying  an operation  to a dangerous  or
 very troublesome extent, for the internal
 orifice may heal, when the external outlet
 gives free exit  to the discharges.   With
 these remarks premised, we will  pass  to
 the consideration of the different methods
 and instruments employed in the treat-
 ment.
   b. Method by regimen and local appli-
 cations.  The  records of surgery, from the
 days  of Avicenna  to those of Le Dran,
 contain recommendations of numerous lo-
 cal applications,  baths, mineral  waters,
 &c, for the cure of fistula in ano; there
 is scarcely an  article now employed in the
 treatment of ulcers, unless of modern dis-
 covery, which has not  had  its advocates
 either  in  or  out of  the  profession; but
 many of these boasted panacea? received
their death-blow  in  failing  to arrest the
progress  of the  disease in  Louis XIV.
Still we occasionally meet with cases of
 success by such means, in more  modern
 annals.  Pallas was an advocate for this
 method of treatment,  and Evers recom-
 mends the injection of gum  ammoniac.
 Two cases are stated to have  been cured
 under the use of mercury, by Dr. Potter
 (Baltimore Med. and Phys. Journ. 1.119.),
 and the frequent  attempts still made by
 most practitioners before proceeding to an
 operation,  are  a sufficient proof that the
 idea  of success by this method is not yet
 wholly abandoned.  It is by no means dif-
 ficult to appreciate the just value  of such
 measures, but all detail  of the various re-
 medies employed would be misplaced  in
 this  article.  The  few cases  of sponta-
 neous cure will not warrant the hope of
 eradicating fistula in ano by treating it as
 a simple  sinuous  ulcer; but the  attempt
 may diminish the  extent of the disease  in
 bad cases, and simplify very greatly the
 necessary  surgical  operation.  This  fact
 appears  to have  been  neglected  by all
 writers on the subject.
   We may  mention as varieties  of this
 method, the plan of dilating the orifice by
 means of  tents, and that of introducing
 setons to irritate the sinus, both of which
 are now justly discarded.   Had  the  idea
 suggested  itself to the advocates of the
 former method, that the  introduction of
 tubular, instead of solid tents would have
 secured instead of arresting the free dis-
 charge of the secretions, the consequences
 would have been more happy; and we are
 by no means sure  that this plan might not
 be acted upon with advantage in extensive
 external fistulae, the canula being intro-
 duced for  a  short distance, and there re-
 tained until the deeper portion of the ca-
 vity has been  allowed to  contract when
 the cure  could be  readily completed by
 other means.
   c.  Method by caustic. Two causes con-
 spired to render this method popular, from
 the time of the earlier Alexandrine wri-
 ters, to the conclusion of the middle  age
 of surgery.   These  were, firstly, the mis-
 taken idea that the indurations with which
 fistulae and abscesses are often surrounded
 require to  be maturated and removed be-
 fore the parts can be reunited;—an idea
 which we  should consider as  belonging
 only to the history of the science, were  it
 not for some scarcely ambiguous traces of
 its practical  influence  exhibited  in  the
 writings of certain  more  recent French
 surgeons;—and secondly, the dread of the
 knife, so natural  in the infancy of ana-
 tomical knowledge.  In modern times, the
method by caustic  is resigned to the em-
pyrics, or if used by  regular practitioners, 
142
ANUS. (Fistula.)
it is only in culpable condescension to the
unfounded  fears of the  patient and even
then it is only employed as a substitute for
the knife in laying open the canal or in re-
moving partial septa.  It may be wrong to
condemn it in  every case and under all
circumstances, for the destruction of the
pseudo-mucous membrane in this manner
might facilitate the recover}' under the
measures of which we are  now about to
speak, if these measures should hereafter
receive the sanction of the profession.
  d.  Method by excentric compression.
This very  ingenious  method consists in
distending  the anus and pouch of the  rec-
tum in such a manner as to close the in-
ternal orifice, if the  fistula  is complete,
and to remove the mechanical forces which
oppose the  obliteration of the sinus.  The
first proposition of this method is due, ac-
cording  to Velpeau,  to M. Bermond of
Bourdeaux.  It consists in two concentric
metallic canulae, the external one covered
with some  tissue (une double canule a
chemise), which is introduced empty and
closed into the anus.  Lint, sponge, or
some other suitable substance, is then in-
troduced between the external canula and
the  cover,  until the rectum is sufficiently
distended, and the whole apparatus is sup-
ported by  suitable compresses and  ban-
dage until the sinus has cicatrized. When
a stool is  required,  the  internal canula,
which ends in a cul-de-sac, is withdrawn,
and  the external one remains open at both
ends, for the passage of fasces or the ad-
ministration  of  injections if necessary.
(Theses  de Paris, No. 44.  1827.  p.  23.)
M. Colombe, about  the  same time,  em-
ployed for  a similar purpose a hollow cy-
linder of ebony or gum elastic, retained in
the  anus by ribbons attached externally.
(Bibl. Med. II.  1828.)  M. Velpeau, who
does not seem  to anticipate great advan-
tages from  this method, prefers the appa-
ratus of M. Bermond, as he has seen M.
Colombe compelled to renounce his plan
in one instance, in consequence of a pro-
lapsus of the mucous coat of the rectum
into  the superior orifice of the cylinder.
(Diet, de Med. III. 328.)  The success of
the method has not yet been sufficiently
tested, but  we confess our doubts of the
possibility of retaining any very consider-
able  mass of compress in the pouch of the
rectum for  a sufficient length of time.  In
extensive fistula, whether complete or ex-
ternal, the  effect would be prejudicial by
retarding the exit  of the discharges from
the deeper-seated parts.   Even if the ex-
ternal portion of the canal and its internal
orifice were closed by adhesion, there
would be great danger  of converting the
disease  into an  abscess  or cyst  which
would reproduce the fistula.  The method
seems then  to be applicable  chiefly to
cases in which the sinus does not  mount
above the superior margin of the internal
sphincter; and if the apparatus of M. Co-
lombe could be so modified as to remove
the objection of M. Velpeau, it might then
perhaps obviate the necessity of an  opera-
tion, which, however, is by  no  means se-
vere in such cases.
   e.  Method by external compression.
This  mode of treatment is difficult  and
troublesome; it consists in the application
of compresses which fill the lower part of
the anal canal without  passing the point
of greatest constriction of the  external
sphincter,  and which are continued over
the superficial part of  the  sinus.  They
are supported by bandages which  act with
very little certainty, owing to the form of
the parts.  The method is still frequently
employed, and sometimes  with  success.
It is  applicable only to complete fistulae
of which  both openings are visible from
without, and which have no internal pro-
longations.   It is, even in these,  liable to
greater objections than the knife, and in
all other cases it must prove positively in-
jurious by arresting the discharges.  We
have  noticed it  only because we have
several times seen it misapplied.
   f.  Method by ligature. This consists in
the introduction  of a ligature  of thread,
silk, tape, or flexible metal, which is made
to pass through both orifices of the fistula,
if it be complete, and  also through  the
anus; or  if it be external,  a new orifice
is made into the rectum as near as possible
to the upper extremity  of the cul-de-sac,
and the  case is then treated as if com-
pletely mature.  The two  extremities of
the ligature, dependent from the external
orifice,  and from the anus, being tied or
twisted together, or included in a  single
or double canula, the whole  septum inter-
vening between the sinus and the rectum
is included in the loop.   The weight and
tension  of the cord produce a gradual ul-
ceration of the septum, and this  yielding
before the pressure,   granulations  are
formed  upon  the  surface  of the  sinus,
which thus becomes obliterated above, as
the ligature  cuts its way to the  surface.
The loop is tightened as it becomes slack,
and it is  thus contracted with a rapidity
proportioned  to the  irritability of the pa-
tient and the thickness of the septum.
  This  method is of ancient date.   It is
described  by Hippocrates  (De Fistula),
and very  little  improvement  has been 
ANUS. (Fistula.)                            143
made upon his plan of performing it until
within a few years. Although by no means
universally employed, the timidity of the
earlier surgeons rendered it a favourite
practice, down to the days of Dessault,
and perhaps it has never been wanting in
advocates even since that period.  Founded
on the fear of hemorrhage, a dread which
the light of anatomy has now in great de- .
gree removed, it deserved a high prefer-
once over most of the rude  measures for-
merly employed in deep incisions, com-
plicated as they were with precautions
against  bleeding,  cruel  in  their nature,
and  entirely  unnecessary.   Perhaps the
greatest objection to this mode of treat-
ment as then practised was, its combina-
tion with the method by caustic.  The
ligature is but seldom employed at pre-
sent  M. Velpeau declares that it has
scarce any partisans (Diet,  de Med.  III.
327.), and Mr. Samuel Cooper says it is
justly abandoned in England. (Surg. Diet.
Art Anus.)   The  principal  arguments
against it are  the slowness of its action, the
excessive pain to which it sometimes gives
rise, and the nervous symptoms that occa-
sionally supervene.   From  three to six
weeks are often required for the entire di-
vision of the septum, and the sufferings of
the patient have been known to  compel
the  surgeon  to resort to the knife before
the  completion  of the process.   On the
other hand, it should be  remembered that
all these objections apply with most  force
to the division,  by ligature, of the lower
part of the septum, where it is covered by
the skin and the lining membrane of the
two inferior portions of the anal canal.  It
is here  that the ulceration proceeds  most
slowly,  that the sensibility of the parts is
greatest  and it is here also that injuries
or inflammation  produce the most severe
sympathetic symptoms (see *> 11.); but the
very reverse  is  observed in the parts co-
vered by true mucous membrane, when in
a healthy condition.  The difficulties above
mentioned are by no  means observed in
every case;  we have  seen  the  operation
repeatedly performed and completed  with-
out occasioning any very serious suffer-
ing; much depends on  the condition  of
the patient at the time; and the attempt
to  apply the ligature,  or even to  explore
the sinus, when the parts are highly irri-
tated or  inflamed,  is altogether  unwar-
rantable ; leeches, fomentations, or emol-
lient poultices, with proper  general treat-
ment should always be premised in such
cases.  Dr. Gibson strongly  insists on this
course even  when the knife is employed,
although  the hemorrhage which follows
the incision is well  calculated to  lessen
the evils resulting from the introduction
of the  instruments.  (Elem. of Surg. II.)
  It is in vain to pretend that  the hemor-
rhage is never dangerous and seldom trou-
blesome after the use of the knife in cases
which  require the incision to be  carried
high up upon the rectum,  where  large
branches, or the main trunks of the middle
hemorrhoidal arteries may be unavoida-
bly cut; and  under  such circumstances,
the  method we are  now discussing en-
joys very  great  advantages,  unless, as
rarely  happens, the upper part of the sep-
tum is thick, indurated, and very unyield-
ing. It is by no means necessary that the
operation, though commenced by the liga-
ture, should be completed by it. Dr. Phy-
sick in his lectures, and  Dr. Dorsey in
his surgery when commenting on the ope-
ration  of Dessault  for very extensive
fistulae, state that it often facilitates the
cure to lay the sinus open by incision as
soon as the loup has become  so far con-
tracted that the whole remaining portion
of the  septum  is within reach of the knife.
(Elem. of Surg. II.  164.)  Within a few
days, Dr. B. H. Coates  has modified this
method in a manner still different.  Ob-
serving that ligatures applied to  mucous
membranes divided them very rapidly and
with little pain, while those applied to the
common integument advanced with diffi-
culty  and  gave great  inconvenience by
their pressure, he resolved to commence
the operation  for fistula in ano by an inci-
sion through all the parts between the ex-
ternal orifice,  and the edge of the mucous
membrane at the lower margin of the in-
ternal sphincter, and then to proceed with
the division of the  superipr  part of the
septum by the ligature.  This he effected
by passing a sharp-pointed bistoury through
the sinus and  its parietes at the point spe-
cified, to the finger in the anus.  After
completing the incision in the usual man-
ner, he again  punctured the mucous mem-
brane  from the cul-de-sac of the  sinus,
somewhat more than an inch higher up in
the canal.  A wire being carried through
this second puncture, and drawn out from
the anus, the ends were secured together,
and the union of the incision prevented
 by the dressings.  The ligature came away
on  the fourth day,  without having been
tightened. The patient  is doing well, but,
owing to rather extensive attenuation  of
the skin around  the original orifice, the
 case is still pending. This is another ap-
 plication of the principle upon which rests
the operation of Dr. Physick for removing
tumours of the anus  by  ligature (see J; 9); 
144                            ANUS. (Fistula.)
  it seems preferable to the plan last men-
  tioned, because it relieves the very sensi-
  tive margin  of  the  anus from  irritation
  during the whole progress of the  treat-
  ment
     In estimating the value of the method
  by ligature, it is right to mention that no
  p.rtiry  of difficult access and important
  size is seated in the  perineum below the
  fascia media,  or ia the recto-ischial exca-
  vation.   The lower hemorrhoidal arteries
  may be seen and secured, if they should be
  divided and should bleed profusely, which
  is seldom the case. The loss of blood con-
  sequent  on the  incision of the part, is
  generally advantageous to  the patient in
  this disease. The history of the operations
  for fissure, and the excision of the rectum,
  clearly shows that bleeding,  even from
  free incisions in the  superior portion  of
  tiie anal canal, seldom demands the  inter-
  ference  of the surgeon, and is easily ar-
  rested when it occurs. The nature of the
  operation precludes the danger of occult
  hemorrhage in fistula in ano which does
  not extend above the upper edge  of the
  internal  sphincter.  These dangers fur-
  nishing  the only pleas in favour of the
  ligature,  this  method  appears to us inap-
  plicable in fistula  which does not  pene-
  trate beyond the spot just specified.
     If the views which we have givemwhen
  speaking of external blind fistula extend-
  ing high  onto the rectum be correct the
  method  is  equally inapplicable • in such
  oases; for we hold that  the required inci-
  sion should be confined to that portion of
  the septum which lies between the  sinus
  and the anal canal; but this opinion  is ad-
  vanced with diffidence,  for the weight of
  authority is against it. (See p. 140.)  But
  the case  is widely different when a true
  stercoraceous  fistula  opens into the rec-
  tum far above the  anus; the difficulty of
  securing  any  vessel  thus  situated;  the
  large size  of the arteries often involved,
  particularly if the sinus is located near
  the posterior part of the intestine;  the
  great danger  of concealed hemorrhage;
  and above all,  the directions given by the
  advocates of the knife, for the arrest  of
  the bleeding in cases of difficulty; render
  it  at least  doubtful whether the ligature
  has not been too sweepingly condemned.
  Either of the modifications of this method
  which have been noticed above, are suffi-
  cient to exempt it from most of the objec-
  tions urged against it and it  is certainly
* much more safe than that of incision.  M.
  Velpeau (Loc. Cit.)  states that It seldom
  succeeds when  the  sinus  has  several
  branches, and that even in simpler cases
it is not always more fortunate. The same
remark may be  made  of all the methods,
and there are not to be found a sufficient
number  of  well-observed cases,  to war-
rant us in making a comparative estimate
of their  success.  The hemorrhage from
the use of the knife, in the>e deeply seated
fistulae, has been  known to prove fatal;
fortunately they are very rare.  W'e have
dwelt  more  fully upon this subject be-
cause the ligature  is not abandoned in this
country; perhaps it may be too frequently
employed, and it therefore becomes highly
important to point out .the cases in which
it is improper, as well as these  to which
it is well adapted.
  The materials of which the ligature has
been formed have been exceedingly va-
rious.  Hair, bristles, cords  of silk, hemp
smooth or knotted, &c, were used by the
ancients. Foubert introduced leaden wire,
which is  still in use; other flexible metals,
such as silver or annealed iron, have been
more recently employed, and tape or strong
bobbin is now frequently used.   It would
be useless to quote authorities on a point of
so little apparent importance, but  the se-
lection of a  proper material is not alto-
gether a matter of indifference.   In pro-
portion to the form and nature of the liga-
ture, will be the rapidity of the ulceration
it occasions, and also the severity of the
irritation it produces—both  of which are
occasionally important considerations. Of
all  the  materials  mentioned,  the leaden
wire is perhaps the least and the bobbin
or cotton cord the most irritating.  The
metallic  wires  possess the advantage of
firmness, which  may enable the surgeon
to introduce them in some cases without
the  aid of any other instrument;  but they
are  more likely, on this very account to
produce mischief to the mucous membrane
in the attempt  to bring the extremity
down to  the anus, and they cannot be
made to embrace the septum so evenly as
more flexible cords.
  There  have been several modes  recom-
mended for  the  introduction of the liga-
ture, the oldest of which  is the  Hippo-
cratic.    The  author   employed a blunt
pewter eyed probe, which he armed with
his  ribbon of thread and horse-hair,  and
passing its extremity into the rectum, he
brought it down with the index finger of
his left hand placed in the anus; then with-
drawing  the probe by this extremity, the
ligature was carried through the sinus and
anal canal—its ends were tied externally in
a sliding knot, and tightened as usual, from
time to time, until the septum was com-
pletely divided.  A similar mode  is still in 
ANUS. (Fistula.)                            145
use, except that the probe is now made of
silver.   The  chief objection to it is the
difficulty of bending the extremity of the
probe in the rectum, without a very pain-
ful traction on the septum.  This difficulty
becomes greater, when the internal orifice
is located high on the rectum; and insu-
perable, when it rises above the reach of
the finger.  The advocates of extensive
incision in external blind fistula, found it
necessary to  puncture  the rectum  at a
considerable  distance from the  anus, in
order to  use  either the  knife or the  liga-
ture ; and we owe to Ambrose  Pare the
introduction of the canula and stilet for
this purpose.  He employed a curved tube,
through which he passed a long lancet-
pointed needle,  and with  this  he pene-
trated the rectum to the finger introduced
per anum.  This surgeon, and his pupil
Guillemeau, when they used the ligature,
employed the curved canula as a guide
for  its  introduction.  Dessault modified
the plan of Pare, but  rendered it more
complex  without any material  improve-
ment.  If the original internal orifice, or
the puncture  made by  the surgeon, was
placed beyond the reach of the  finger, he
seized the ligature when it left the canula,
with a forceps  of peculiar construction,
called  a  pince gorgeret, and he secured
the dependent extremities of the wire by
passing them through a flattened canula
and doubling them upon notches made for
the purpose in its lower  margin. (QZuvres
Chir. II. 388.) The use of forceps in the
rectum,  requires great  care, and  should
not be resorted to without strong neces-
sity ; but the  method as  practised by  Des-
sault  is still  viewed with favour by those
who approve  of the ligature in very deep
fistula?.  Dr. J. K. Mitchell has invented
an instrument which has been sometimes
employed for the passage of the ligature.
It is a forceps, with long arms, curved at
their extremities, and  meeting only at
their points. These arms are tubular, each
forming a steel canula open near the joint
of the  instrument and at the extremity of
the blade.  When closed, there  is a con-
tinuous canal throughout  the blades; the
joint is  formed like that of a  midwifery
forceps;  and the arms are intended  to be
introduced separately—one into the  anus
—the other into the cul-de-sac of the sinus.
The blades being then adjusted, locked,
and closed, a  long, sharp and flexible steel
needle is passed up the  canula in  the si-
nus, penetrates the rectum, if  necessary,
«nd returns  by the  canula in  the  anus,
without the possibility of leaving its track,
or injuring the surrounding parts. (Amer.
  vol. ii.          13
Journ. of Med. Sciences. II. 843.)  This
instrument is certainly constructed with
great ingenuity, but there must be much
difficulty in the introduction  of two such
canulae,—the one, through a canal nearly
straight, the  other, through a sinus often
very tortuous,—in such a manner as to
bring the blades of the forceps into proper
relation with  each other;  a  difficulty in-
creased by the curved form given to  the
ends of the arms.
  By far  the  most beautiful plan which
we have seen suggested for the introduc-
tion of the ligature is that proposed by the
present Professor  of Surgery in the Uni-
versity of Pennsylvania,  We have been
politely permitted by Dr. Gibson to take a
drawing of this instrument, intended only
for  deep-seated fistula in ano, such alone
requiring the ligature.  It consists of,  1st,
                         a flat silver ca-
                         nula (a), slight-
                         ly curved,about
                         five  inches  in
                         length, £th of
                         an  inch broad,
                         having a small
                         oval ring near
                         one extremity,
                         for the purpose
                         of  holding  it
                         steady;—2d,  a
                         steel stilet  (6),
                         lancet-pointed
                         at one end, and
                         armed with  a
                         button, or  cir-
                         cular  disc,  at
the  other;  which  is  intended to  pass
through the  canula, and to  be  projected
beyond it,  so as to penetrate the rectum,
if the fistula has no internal  opening; its
dimensions are such that it fills the canula
completely;—3d, a portion of a fine watch-
spring (c), with a lenticular button at one
extremity, sufficiently large to fill the ca-
nula, but small enough to glide through it
with ease; and the other end  furnished
with an eye, and armed with a ligature,
which Dr. Gibson generally forms from a
piece of French braid.  The canula having
been passed into  the  sinus to the desired
depth, the puncture effected, if necessary,
and the stilet withdrawn, the elastic nee-
dle or spring is introduced; its blunt  end
passes into the rectum, and immediately
descends  toward  the  anus,  where it  is
easily caught by  the  finger.   The whole
length of the spring is now drawn through
the anus, the ligature follows, it is then
detached from the eye of the spring, the
canula is removed, the dependent extrerni-
 
146                            ANUS.  (Fistula.)
 ties of the braid are tied as usual, and the
 operation is complete.  This mode of treat-
 ment is free from all the objections urged
 against the ancient plans of the probe and
 wire; it is simple, rapid, very easily per-
 formed, and frees the patient from the pain
 produced by the pressure of the latter in-
 struments when the surgeon is endeavour-
 ing to  bend them in the rectum.   Pre-
 ferring, as we do, the knife in every case
 of fistula  not  extending above the  anal
 canal, and believing the extensive division
 of the septum  in external  incomplete
 fistula,  to be seldom or never necessary,
 we should not often employ the stilet in
 the above described  apparatus; but be-
 lieving the ligature greatly preferable to
 the knife,  for dividing the upper part of
 the septum  in true stercoraceous fistula,
 we cannot but esteem the instrument of
 Dr. Gibson a very valuable addition to the
 apparatus chirurgica.
   g.  Method by incision. Having already
 enlarged upon the just value of the danger
 of hemorrhage as an objection to the use
 of the knife; and having  also expressed
 our opinion as to the extent to which the
 division of the septum should be  carried
 in  cases of external incomplete fistula, it
 is only necessary to add a few words upon
 the plan  formerly styled  the  method by
 excision,  before  we  proceed  to analyze
 the apparatus,  and describe the operation
 of incision.
   The plan of laying open the whole route
 of the sinus in fistula in ano by sharp in-
 struments, is quite as ancient as either of
 the methods already  noticed; for it  is
 hinted at—though without sufficient de-
 tails—in the Hippocratic treatise to which
 we have already referred.   But the older
 authorities were constantly misled by the
 notion that the callosities and indurations
 consequent on the inflammation of  any
 part were malignant alterations of struc-
 ture,  requiring  removal  before a  cure
 could be effected.   Those, therefore, who
 did not accomplish this purpose by caustic
 applications, generally followed the advice
 of Albucasis, Jean de Vigo, Durand Sac-
 chi, and  Severinus,  who employed the
 actual cautery  after the operation; that
 of Guy  de Chauliac, who made his inci-
 sion by means of a red-hot bistoury intro-
 duced on  a grooved sound; that of Cel-
 sus, who excised the interior parietes of
 the sinus;  that of Leonidas,  who care-
fully removed all the callosities by means
of a forceps, a knife, and a peculiar specu-
 lum;  or lastly,  that of Dionis, who con-
tented himself with scarifying the indura-
 tions  after having laid open  the sinus.
 All these modes of proceeding have been
 finally relinquished, except those of Cel-
 sus and Dionis, of which traces are still
 discoverable in the  directions of Boyer
 and Roux for  operating  on deep-seated
 fistulae; directions still advocated by many
 continental surgeons, and which  appear
 to have received the sanction of Velpeau.
 (Med. Operat. III.  1024.)
   At  present  neither scarifications nor
 excision are at all recommended in Eng-
 land or this country, unless when the skin
 around the external orifice  of the fistula
 has become so completely attenuated that,
 while it still retains  its vitality, it is alto-
 gether incapable of effecting a union with
 the surface beneath;—a condition seldom
 observed  except in  persons of depraved
 constitution.  The propriety of excising
 the flaps  in such cases,  need not be dis-
 cussed in the present article.  The same
 difficulty is often presented  in cavernous
 ulcers of other parts, and in certain bu-
 boes.   We will merely remark that the
 sensibility of the flaps in such cases,  is
 almost destroyed, and hence, no operation
 upon  them produces  much  pain,  unless
 carried beyond the necessary limits.  We
 have  been convinced by  numerous com-
 parative observations that the  application
 of caustic  alkali is decidedly more bene-
 ficial  than the knife, for  their removal;
 for the more extensive  and longer  con-
 tinued action required for the  separation
 of the sloughs, increases  the vital action
 of the  surrounding parts, and promotes
 the rapid cicatrization of the  surface.
   The  earliest recorded  instrument for
 laying open  the 6inus of a fistula in ano,
 is the syringotome of Galen (Meth. Med.
 lib. vi. cap. 4.), a falciform knife, with a
 probe point, having its concave edge sharp-
 ened  like  a  bistoury.  It  was  used as a
 hook, and  was passed through the outer
 and the inner orifice into the rectum, car-
 ried out through the anus,  and then being
 drawn downward,' it divided  the  whole
 septum.  If the fistula was incomplete,
 the rectum was first penetrated in some
 of the modes already noticed  when speak-
 ing of the method by ligature, or the blunt
 point  of the syringotome was made to
 penetrate  the thin  parietes of  the  canal,
 and the operation was then completed as
 before.  This instrument underwent very
 numerous modifications  in the hands of
 succeeding surgeons.  Its  extremity  was
generally  attenuated and  deprived of  a
cutting edge, for a  sufficient distance, to
allow  it to pass through the  sinus before
it commenced the incision. This rounded
extremity was  afterwards replaced by  a 
ANUS. (Fistula.)
147
flexible probe, soldered to the extremity
of the knife.   Leonidas,  whose mode of
operating was complex, and required the
speculum, used an instrument resembling
the curved bistoury with such a stilet at-
tached (Andrea a Cruce.  Officin.  Chi-
rurg. p.  43.), which is said to have been
first made movable by means of a screw,
by Lemaire of Strasbourg. (Diet,  des Sci-
ences Medicales. LIV. 163.) Felix, Di-
onis, and Bassius, employed instruments
of very  similar construction. (Sprengel.
Hist, de Med. VII. 275.; Heister.  Inst.
Chir.  Tab. 25.)  Dr. Rodgers of New-
York,  has given to the knife of Leonidas
the greatest degree of  improvement of
which it is susceptible, by appending the
movable and flexible probe of Lemaire to
a curved bistoury, nearly on the model of
that used by Mr. Pott (New - York Med.
and Phys. Journ.), a modification some-
what similar to that of Larrey, who uses
the same kind of a stilet appended to  a
grooved  director. (Velpeau. Med. Operat.
III. 1019.)  Paulus ^Egenita reduced the
operation almost to its present simplicity,
by sometimes using a common bistoury,
with which he divided the septum upon his
finger introduced into the rectum; but he
had a needless  dread  of wounding the
 sphincter muscles. (De re medica. lib. vi.
 cap. 78.) This mode, long neglected, was
 finally revived by Mr. Pott (Chir. Works.
 III. 71.), whose curved bistoury is still in
 use and takes place of most other instru-
 ments in  American  practice; though a
 sharp-pointed one is substituted  when  it
 becomes necessary to puncture  the rec-
 tum or  anus.  A straight bistoury is pre-
 ferred whenever its form is adapted to the
 direction of the sinus.
   The grooved sound, as a director to the
 knife, in making the incisions, was intro-
 duced by  J. L. Petit, when he  rejected
 the elongated beak of  the syringotome,
 because he found its introduction. painful
 and difficult.  (Traiti de Mai. Chir.  II.
 223.)  It is generally made of flexible ma-
 terials,  so that it may be brought out at
 the anus when the internal orifice is not
 too deeply seated; and  it still continues
 in very  general use.  In cases where the
 incision does not extend above the middle
 region of the anal canal, its application is
 not troublesome; but  the bistoury of Dr.
 Rodgers is more simple, because it serves
 the double  purpose of  a  director and a
 knife.   When the internal orifice is more
 deeply seated, both these instruments are
 objectionable, because  neither   can  be
 brought to the anus without very painful
 pressure upon the septum. If the director
be employed, simply as a guide to carry
the knife  into the rectum, without reap-
pearing at the anus, an assistant becomes
necessary, because the surgeon has the
index of one hand engaged in the anus,
while the other hand  is wholly occupied
with the knife.  In such cases, some modi-
fication of the guarded bistoury is greatly
preferable.
   The  scissors, first brought into notice
for the division of the septum in fistula in
ano, by Wiseman, were  very justly  con-
demned by Petit;  but they were em-
ployed by Boyer for removing flaps of de-
nuded intestine, and are still in use among
the advocates of excision.
   Those who resort to incisions in  very
extensive fistula, are  sometimes obliged
to employ an instrument to receive the
point of the director, or the bistoury, when
it enters the rectum beyond the reach  of
the finger. For this purpose, Marchettis
contrived the rectal gorget.  (Sprengel.
 Op. Cit. VI. 272.)  This  is nothing but
an enlarged director, made of metal, or  of
wood,  and sometimes having its groove
partly interrupted by ridges, to give greater
fixedness to the point  of the instrument;
for it has undergone many modifications,
by Bassius,  (Haller.  Diss. Chir.  IV.
480.);  Rungius, (Heister.  Instil. Chir.
CLXVIII. cap. ix.  tab. 25.); Benjamin
Pugh  (Treat, on  Midwifery,  p. 144.);
and Percy (Journ. de Med. LXXII. 175.).
It was employed  by De Lange, Saba-
tier, and Boyer, but for different pur-
 poses.  It is still used by Roux. (Velpeau.
 Med. Operat. III. 1024.)  Having  given
 decided preference to the ligature in  di-
 viding  the intestinal  portion of the sep-
 tum, we shall offer no  farther  comment
 upon this instrument except that when
 formed of wood, it is well adapted to the
 end in  view.   Percy and  Sabatier used
 it to facilitate the application of dressings.
   There is one  objection against all the
 knives yet mentioned;  an objection not
 removed by the use  of the  grooved  di-
 rector, or the gorget  This is the pain oc-
 casioned to the patient by the action of the
 edge on the walls of the sinus, before the
 point has entered the rectum or anus; and
 to remove this,  the various forms of the
 guarded bistoury  have been contrived.
 The first appearance of the guarded bis-
 toury,  was in the reign of Louis XTV.,
 who was operated upon by Felix with an
 instrument hence called Bistourie Royale,
 which  we have  already described.  The
 cutting edge of this instrument was  co-
 vered  with  paper,  until  the stilet had
 passed  entirely through the sinus, followed 
148
ANUS. (Fistula.)
by the sharp part of the blade:  the paper
was then withdrawn and the incision com-
pleted. So great was the reputation gained
by this operation, that according to Dionis,
all the courtiers  of France who were  so
fortunate as to have any complaint of the
anus, pressed upon Felix, to imitate the
example  of the monarch, and were sorely
disappointed if the nature of their case did
not call for surgical assistance.  The royal
disease became fashionable, a mark of bon-
ton—as Mad. Sevigne expresses  it (Let-
tres.  X.  176. Edit. 1823.),  and this cir-
cumstance exerted  a wide-spread  and fa-
vourable  influence on surgical practice for
a considerable period; but the instrument
has been long abandoned. Senff of Berlin
contrived a syringotome cache upon the
model of the guarded hernial bistoury of
Garengeot.  This  instrument we have
never seen: it was strongly recommended
by Platner  (Sprengel.   Op.  Cit.  VII.
276.), and many contrivances of the same
character followed,  but few of them have
continued long  in use, if we except, in this
country,  the well-known guarded bistoury
of Dr. Physick (Dorsey. Elem. of Surg.
II. 162. pi. xxii.): the only objections urged
against this last arise from the <too great
acumination of the blade, and the slight diffi-
culty sometimes experienced in detaching
the little hood of the guard, which receives
its point.  The knives of Cruickshank,
Savigny, and Whately, have been but
seldom employed in America.   The most
perfect instrument of this class is, perhaps,
that recently described by Dr. Mutter of
Philadelphia (Amer. Journ. of Med. and
Phys. Sciences. XIV. 80.), and we have
therefore given a representation of it as
since  modified and
improved. It is found-
ed on the principle
of the lythotome ca-
che, and consists of,
1st,  a   steel  staff
with a wooden han-
dle,  and  provided
with a  tenant-joint
(d), from  which, to
the  extremity, it is
grooved  to a  suffi-
cient depth to con-
ceal  the  blade  of
a  bistoury;—2d,  a
steel blade (c) and
handle (a) intended
to be secured  by a
screw which passes
through   the   joint
(d).  At the  joint
the   blade  is   fur-
nished with a mortise, partly seen in the
left-hand figure, which permits it to slide
upon  the  screw, so  as to cause the point
to project a little beyond or to be retracted
a little within the groove of the staff' The
handle of the blade is  furnished  with  a
short  steel pin (b), which, when the point
is projected,  rests on  the handle of the
staff, and prevents the cutting edge from
leaving the groove,  but which,  when the
point  is fully  retracted,  is received into a
hole in the handle  of the staff, and the
blade  is then made  to  appear, as in the
right-hand figure. This instrument is used
as follows: The point being retracted and
the blade concealed, the staff is introduced
into the sinus, and the finger of the unoc-
cupied hand, into the anus.  The instru-
ment  is then employed as a sound.  If the
fistula is  complete,  it is passed through
the internal orifice, and  the handle of the
blade   being  depressed,  the  incision is
made with the finger in ano resting both
on the point of the staff, and that of the
knife.   If the  fistula is incomplete, the
place for puncture is chosen, the point of
the knife is thrust forward, and the rectum
perforated ; the point is then drawn back,
the instrument passed through the orifice
thus made, and the operation is completed
as before.
   There are many other instruments and
modes of operating on record, but we have
confined our attention to such as have ex-
erted most influence upon the practice of
the present day; and after the very great
variety of plans already enumerated,  it
will be reasonably expected that we should
give a summary of our own selection.  In
complete fistula in ano having its interna]
orifice below the margin of the internal
sphincter,  the knife should be employed
invariably, and the incision should include
both openings. When the internal orifice is
in the superior portion of the anal canal, we
equally prefer the knife.  When it is still
more  deeply situated, we must decide ac-
cording to the condition of the septum. If
this is firm, thick, and indurated, the knife
is still indicated, because the ligature acts
very slowly and produces great irritation
under such circumstances; but if the inter-
nal parietes are thin, which is almost always
the case, the ligature is preferable, and \\>■
should wait until it has ulcerated nearly or
quite to the edge of the mucous membrane,
and then divide the remaining portion with
the knife,—unless,  on  farther  trial, the
method  pursued  by  Dr. B. H. Coatem
should  hereafter  claim  a  preference.
When  the orifice  lies very  high  in the
rectum, the intestine, or its  mucous coat 
ANUS. (Fistula.)                            149
only, are simply denuded; in these cases,
incisions, if not very dangerous, are at least
liable to occasion very  troublesome he-
morrhage,  and sometimes render neces-
sary the actual cautery; the ligature  is
here decidedly preferable, but the cases
are very rare.  We can see no reason why
the ligature should be inapplicable, as most
surgeons pretend, when there are several
internal orifices; nor can we perceive any
motive for avoiding its use, when the same
fistula has several external outlets: these
may be laid into one, by incisions, without
disturbing  the progress  of the ligature.
When there are many fistulae coexisting
in  the  same individual,  the  necessity of
performing several operations  at different
times, for their relief! depends on the con-
dition of the patient
   In external incomplete fistula, we should
be  content with puncturing the anus near
the upper end of the anal canal, on a level
with  the upper surface of the external
sphincter, and then proceeding as in com-
plete fistula.
   In incomplete internal fistula presenting
below the fascia media, the sac should be
punctured by  a thumb lancet, or  opened
by cutting with a scalpel or bistoury, upon
the bent probe of Dionis, introduced from
the anus. We have never seen cases such
as  are mentioned by  Velpeau,  which,
seated between the fasciae, open internally
without approaching the surface; but  if
the physiological  views  we  have given
(Vol. II. p. 139.) are correct  they would
probably recover  if the internal  orifice
were simply enlarged.   If not they must
ultimately assume some other form,  or
prove beyond  the aid of art.
   With regard to the selection of instru-
ments ;—in the first-named class of cases,
the straight  or curved blunt bistoury,
or  either of  the sharp bistouries with
the grooved director, may be  used almost
indifferently;  the  knife  of  Rodgers  is
neater, because more simple, and that of
Mutter is scarcely less applicable.  In
all deeper incision*, the latter-named in-
strument and the  guarded   bistoury of
Dr. Physick enjoy the advantage in point
of  simplicity,   in many cases, the knives
in the ordinary surgical  pocket-cases will
answer  the  purpose,  if the  others are
not at  hand;  but as  they occasion un-
necessary pain, they should be dispensed
with, if possible. The danger to the finger
of the surgeon in puncturing the  rectum
is much exaggerated—if the point of the
knife is made nearly square,  as it should
be, and the precaution is  used to complete
the passage rather by cutting than by a
thrust  the  unavoidable incision  of the
finger is too slight to deserve notice.
  The  proper preparation for the opera-
tion by incision consists in lessening, if
necessary, the irritation of the part, and
in bringing the bowels into a regular con-
dition.  A mild laxative may be adminis-
tered the day before, and an enema on the
morning of the operation. Within an hour,
an opiate should be administered, to lessen
the sensibility of the part  and to prevent
discharges.   The diet for  some days be-
fore and after the  incision, must be such
as is calculated to lessen the bulk of faeces,
that the patient may remain undisturbed
as long as possible—but it should be ren-
dered nutritious as soon as the patient's
condition will permit,  in order to hasten
the cure.
  There  are several convenient attitudes
for the patient while undergoing the ope-
ration.   He may be placed as directed in
the section on fissure; he may lay prone
upon the side  of a bed or table, with the
thighs dependent, which is the most com-
mon arrangement;  or he may kneel upon
a bed with his elbows and knees approxi-
mated.   Two assistants should  separate
the nates, while a third, if necessary, at-
tends to the instruments.   The surgeon
employs  the  index finger of one  hand
in the  anus, while  the other is engaged
with the  knife in the sinus.  When the
instrument has penetrated to the finger,
both are  withdrawn pari passu, in  a di-
rection as nearly parallel as possible, and
thus the entire septum is divided with the
least resistance.
   When troublesome hemorrhage occurs,
which is very rarely the case, the vessels,
if seen, should be  tied.  If the incision
has been very extensive, and the bleeding
is internal, we can sometimes discover its
seat  by pressing  the  finger on  various
points in the wound, and it may then be
arrested by ligature; but when this is im-
possible, we must introduce a plug into
the anus, or resort  to  some of the  mea-
sures laid down in the section on tumours.
The pledgets of Petit and  Boyer, of
which the plan of  Dr.  J. R. Barton (see
Vol. II. p. 115.) is a modification, are re-
commended by Velpeau. (Med. Operat.
III. 995.)
  The dressings required in this operation
are very simple.  The main object  is to
prevent union by the first intention, and
for this purpose, as in most cases of a simi-
lar  nature, the French stuff the  wound
with lint and introduce a plug into the
anus; while the English and American
surgeons  are contented with placing a 
150
ANUS.  (Fistula.)
thin layer of lint between the edges, which
should  not be omitted for several days.
M. Velpeau,  however, in reply to a free
stricture of Mr. Samuel Cooper, states that
this difference of treatment is found more
conspicuous in the books than it would be
at the bed-side. Over the pledget,  is laid,
a piece of lint covered with simple cerate,
then  a compress of the same material,  and
others  of muslin,  if necessary,  and  the
whole  is gently supported  by a double T
bandage. The opiate may be repeated if an
evacuation is dreaded at too early a  period.
   The operation by incision, in females,
requires a short notice. M. Ribes remarks
that  there is more danger  of injury from
the knife when carried very high  on  the
rectum in this sex, because the peritoneum
is so differently arranged.  The proximity
of the vagina is also a cause of  embar-
rassment when the sinus is anterior to the
rectum,  and  it then gives  rise, in some
cases, to recto-vaginal fistula.  Moreover,
the fascia superficialis  is  more directly
continuous  with the  fascia media,  and
hence abscesses of the vulva sometimes
 make  their  way to  the anus,  becoming
 complicated with true stercoraceous fistula,
 and requiring the complete incision of the
 whole route of the sinus. M. Velpeau also
 mentions an interesting case of this  nature.

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  See also the General Treatises on Surgery and
on the Diseases of the Rectum and Anus.
                     Revnell Coates.

   ANUS,  ARTIFICIAL or PRETER-
NATURAL.  Anus contre nature, Anus
anormal, Fr.  A permanent opening of
the intestines communicating externally,
either through  the abdominal parietes or
pelvic viscera. It may occur congenitally;
or be accidental, resulting from disease or
injury; and is  sometimes formed  by the
surgeon, as the sole means of preserving
the life of the patient.
  Congenital artificial anus will be treat-
ed of in the articles on the vices of con-
formation, to which  it owes its existence.
(See  Rectum, Intestines, &c.)
  Accidental artificial anus will be con-
sidered with the  diseases and injuries
which produce  it.    (See  Hernia;  Intes-
tines, wounds and  obstructions of, &c.)
  An artificial anus is formed by the sur-
geon, in cases  only of congenital or acci-
dental obliteration  of the  natural passage
for the feces, where it  is impossible to re-
store  this passage.   The exposition of the
methods of performing this operation, can-
not be conveniently separated  from  the
consideration of the disorders which re-
quire  its performance;  the whole will
therefore  be discussed  in  the  appropriate
articles.  (See Rectum, malformation of;
Intestines, obstruction of, &c.)    I. H.
  ANUS, IMPERFORATE.  The term
imperforate anus is  applied to those mal-
formations in which there is  an obstruc-
tion to the discharge of faeces by the na-
tural  outlet.  These vices of structure con-
sist 1st, in a contraction of the anus; 2d,
the closure of this organ by a membrane;
3d, its complete obliteration or entire ab-
sence, no vestige of it existing, the intes-
tinal tube terminating in a cul-de-sac in
the rectum or some other portion  of the
canal, or having a preternatural  opening.
(See  Artificial anus.)
  We shall notice  at present only the two
first-named errors of structure, to  which,
indeed, the  epithet imperforate anus  is
alone  strictly applicable; the last will be
considered in the article Rectum, to which
we must also refer for the anatomical his-
tory of these vices  of formation, as well
as for various other details here omitted in
order to avoid repetition hereafter.
  The existence of imperforate  anus, if
overlooked  at  the moment of birth, soon
makes itself known by a train of morbid
phenomena  resulting from the  retention
of the meconium.  After some hours, from
ten to twenty, have elapsed  without an
alvine discharge, the little patient becomes
restless, cries plaintively, the diaphragm
and abdominal muscles are excited to vio-
lent  expulsive  efforts  during  which the
respiration  is sometimes suspended,  the
face becomes red,  and the abdomen hard.
These symptoms  gradually augment in
violence,  are of longer continuance,  and 
152
ANXIETY.—AORTA.
 appear at shorter intervals.   If no relief
 be afforded, the tenseness of the abdomen
 increases,  especially at its  lower  part,
 which becomes  hot and painful on pres-
 sure.   Soon,  the liquids swallowed, after-
 wards the  mucous  and biliary secretions,
 and finally, matters analogous to meconi-
 um, are ejected by vomiting.  Things con-
 tinuing in  this state, death is inevitable,
 and  takes  place from the  third  to  the
 eighth day, according to the vigour of the
 patient.
   When the  first twenty-four hours after
 birth  elapse without an alvine discharge,
 and some of the preceding symptoms mani-
 fest  themselves, the anus  and rectum
 should be attentively and thoroughly ex-
 plored, so as  to  determine accurately the
 precise seat of the atresia, if it exist, and
 the character of the malformation.  If the
 obstruction be in the anus, it will be found
 to consist either in an extreme contrac-
 tion  of this organ, so that it will scarcely
 admit the finest probe, or its  closure by a
 membrane.
   Extreme congenital contraction of the
 anus must be  remedied by an incision made
 in the direction of the os coccygis, with a
 probe-pointed bistoury; and  the opening
 thus made gradually dilated by the intro-
 duction of a  tent well anointed with sim-
 ple cerate.
   When the anus  is closed by a mem-
 branous diaphragm, this  partition will be
 usually found protruded by the fecal mat-
 ters, forming a roundish  prominence hav-
 ing a doughy feel, and generally of a pur-
 ple or livid hue.  This tumour increases
 whenever the efforts to expel the feces
 are renewed. At  the moment when the
 infant strains and this membrane is most
 tense, a crucial incision should be made
 through it with a straight bistoury, which
 immediately  affords a passage to the feces,
 and with their evacuation all the distress-
 ing  symptoms generally cease.   It  has
 been recommended  to cut  off the angles
 of the membrane formed by the incision,
 but  this seems wholly  unnecessary, as
 they soon retract towards their base  and
 become confounded with the margin of
 the anus.
    For Bibliography, see  Rectum.
                              I. Hays.
♦   ANXIETY.  AXvouos, Gr.;  Anxietas,
  Lat; Anxiete, Fr.  Restlessness; state of
  general malaise, difficult to describe,  in
  which the patient  complains of suffering
  without being able to locate his pains  in
  any particular part  of his body; attended
  with a perpetual inclination to change po-
  sition.  Inquietude is a less and anguish
an exalted degree of this  same condition-
Anxiety has been ascribed to some impe-
diment  to the passage of blood through
the heart or lungs or vena porta, but the
mechanism of its production is not well
understood.  It is usually a very unfavour-
able symptom.
  The terms precordial, pulmonary, and
epigastric anxiety,  have  been given to a
painful  feeling or sense  of constriction,
referred by patients to these regions.
                                I. H.
  AORTA. (Derived, according to some
lexicographers, from aoertouat, I am sus-
pended ; and by others, from aye, air, and
ryeeu, I keep.)  The great artery which
arises from the left ventricle.  Its  situa-
tion, course,  and relations,  will  be de-
scribed  under the head Arteries, where
everything of importance, pertaining to
its healthy condition, will  be found.   The
principal anomalies of its  origin  and dis-
tribution,  and  of the branches which pro-
ceed from it, will be also noted under the
same head.
  It will only be necessary, in this article,
to consider the modifications which take
place in  its form, volume,  texture, and
physiological actions.
  $ 1. Inflammation of the Aorta.  (Aor-
titis.)  The coats of the aorta, in common
with other tissues of the  body, are liable
to acute and chronic inflammation.   The
former, though much rarer than the latter,
probably occurs more frequently than is ge-
nerally suspected.  Incidentally noticed by
Aretjeus and some of his successors, acute
aortitis  did  not attract much  attention,
until J. P. Frank pointed  out its intimate
relations with  the disease usually denomi-
nated inflammatory fever.   Since then, it
has been  particularly described by Span-
GENEERG, JOSEPH FRANK, HODGSON, KrEY-
sig,  Bertin and Bouillaud, Hope, Nau-
mann, and others.  Its pathological char-
acters are, however, still involved in con-
siderable  obscurity,  and  its distinctive
symptoms are far  from  being  certainly
ascertained.   We shall attempt to furnish
a brief exposition of those anatomical char-
acters which have been usually considered
as consequences  of inflammation of the
aorta, either acute or chronic, with such a
description  of the symptoms,  diagnosis,
and treatment of the disease,  as can be
drawn from our present knowledge on the
subject   A minute description,  however,
of the several lesions  of the vessel would
be incompatible with our  arrangement as
it will be necessary to discuss the subject
more in detail, under the head of Arteries,
to which the reader may  refer for that 
AORTA. (Cadaveric Coloration.)
153
additional information which may be ne-
cessary.   We shall first describe  an ap-
pearance which has been often mistaken
for inflammation of the aorta.
   Cadaveric coloration of the lining mem-
brane of the aorta. This character, which
has been so generally regarded as an in-
dication of inflammation, has been shown
by the investigations of modern patholo-
gists, to furnish in itself no positive evi-
dence of that condition.   It is often asso-
ciated with inflammation of the aorta, yet
more frequently exists as a mere cadaveric
phenomenon, where no evidences of disease
can be discovered in the coats of the vessel.
It is now ascertained, that the lining mem-
brane of  the  artery often exhibits deep
red,  violet or brown patches,  strfe and
bands, where no appreciable lesion of tex-
ture can be discovered, and that they are
merely a consequence of a species of co-
loration of the tissue, arising from  imbibi-
tion  of the colouring matter of the blood,
taking place either after death, or  a short
time previous to that event. This opinion,
which was ably supported by Laennec and
Hodgson, has been subsequently corrobo-
rated by numerous experiments  and ob-
servations.  The  redness varies much in
the  intensity and other characters of its
shades.   It likewise differs greatly in its
extent.   Most generally  it is  disposed in
patches, which appear as though a smooth
coating had  been laid  upon  the  lining
membrane of the artery with a brush. Oc-
casionally, however,  it has been found oc-
cupying the whole vascular system—both
arteries and veins.   The spots are some-
times  rounded—sometimes  disposed  in
bands or streaks parallel with each other,
between which the membrane presents its
natural pale colour.  When the colour is
thus limited,  it is oftener found upon the
posterior, than upon any other part of the
aorta.  Sometimes the redness is diffused,
and occupies the entire circumference of
the vessel, and is either a deep scarlet,
cherry red,  violet, livid, or even  brown.
Occasionally it is associated with  a tinge
of yellow, which impresses upon the tis-
sue an ecchymosed appearance.  The red-
ness generally terminates abruptly, and
does not lose itself by insensible shades in
the neighbouring parts, like the redness
which attends inflammation; neither is it,
like  that species of colour, associated with
any arborescent injection of the vasa va-
sorum,  or any appreciable pathological
condition.  It seldom extends to the fibrous
tunic of the artery,  though that tissue is
sometimes found more or less tinged.  Its
intensity is increased by exposure to the
atmosphere, and  by the changes which
take place in the chemical constitution of
the solids and fluids after death. Washing
often removes it  so completely, that the
natural  pale colour of the  tissue is re-
stored ;  but  in some instances it becomes
so firmly set by the inception of putrefac-
tion, that washing,  and even maceration,
exercise but little influence upon it.
  The following  facts furnish  additional
evidence of the non-inflammatory nature
of this species of redness.  It occurs more
frequently in warm than in cold weather,
when of course the rapid progress of pu-
trefaction, and the influence  of  heat upon
the tissues,  render them  more liable to
have incorporated with them  the colouring
matter of the blood by the  processes  of
imbibition or transudation.   It  is greater
when considerable time has elapsed before
the body is opened; increases as  the pu-
trefactive process advances, and  is oftenest
met with in the bodies of those  who have
died of diseases attended with a dissolved
state of the blood,  and a general diminu-
tion of  the  cohesiveness  of the tissues.
Dalmas  remarks, that having  had occa-
sion, in  the years  1824, 1825,  and 1826,
to open a great number of bodies, he ob-
served the appearance in  question much
oftener  in July and August  than in win-
ter, and that it was most common in those
who had died in the surgical wards,  from
protracted suppuration and ataxic  fevers.
(Diet, de Med. 2d edit. III. 392.)  In the
experiments of Rigot and Trousseau, the
same species of redness was produced by
confining the blood within a portion of the
artery, and  they  ascertained that it was
always  greatest in those  cases in which
the blood was black, dissolved, and con-
tained but little serum;—as  in  those who
had died of typhoid and ataxic fevers, or
other similar diseases.  Blood of this kind
was found to produce the  tinge when ap-
plied to a healthy vessel, and in horses in
which it existed,  the  arteries  of the ex-
tremities were not  red, when the  body
was placed upon the back, so as to leave
the  limbs elevated.  (Archiv. Generates.
XII. 119. 333., XIII. 461., XIV. 321.)
  The  redness has besides been observed
in  some  epidemics  and  not  in  others.
Tanchou and Raver often met with it in
small-pox; and in an epizooty which pre-
vailed amongst horses  with great fatality,
in 1825, Dupuy,  Andral,  Girard,  and
Bouley, found the lining membrane of
the arteries presenting this  peculiar red-
ness in a majority of cases, even when the
examination was made half an hour after
death; although Rigot and Trousseau, 
154
AORTA. (Inflammation, and its results.)
who made their investigations in the fol-
lowing year, upon horses dead of the same
disease, did not meet with this condition
of the  blood-vessels.  (Andral.  Precis
d?Anat. Pathologique. II. 351.)  We may
subjoin, that the same appearance of the
lining membrane of the aorta was observed
by  Jaehnichen  and  Markus,  Otto,
Pfeiffer,  and Gescheidt,  in some  of
the bodies of those who died of cholera,
especially  when  the  examination  did
not  take  place until some  time after
death.  (Phoebus ueber den Leichenbefund
bei den Orient. Cholera. 53. Berlin, 1833.)
In this disease, death takes place so speedi-
ly, that little suspicion can be entertained
of the development of inflammation of the
aorta.  Redness of the lining membrane
of the  vascular system is very often ob-
served in  the bodies  of those who die of
purpura hemorrhagica, in which, softness
and laxity of tissue,  together with a dis-
solved  state of the blood exist which  fa-
cilitate imbibition or transudation.  Under
such circumstances, these  acts seem  to
take place to a certain extent even during
life, and if the natural porosity of the tis-
sues be considered,  it can be  readily con-
ceived how  it  may occur  after  death,
and  that too with extreme promptitude,
as in the cases  reported by Andral, who
discovered  it when the examination was
made within half an hour after the ani-
mals had expired.
  Inflammatory redness  of  the  lining
membrane of the aorta.  Acute inflamma-
tion  of the aorta is nevertheless often as-
sociated with more or less redness  of the
lining membrane of the vessel.  Its char-
acter, however, is different.   It is less  in-
tense ;  less diffused, and not so abrupt in
its termination in the  neighbouring parts,
but loses itself by insensible shades.  It is
not limited to the lining membrane of the
artery, but extends to the fibrous and cel-
lular tunics, and is besides associated with
injection of the vasa  vasorum of the two
last  tissues.  Another  important  distin-
guishing mark  is, the association of this
species of redness with a manifest altera-
tion  of texture or secretion, which leaves
no doubt of the existence of inflammation.
Injection of the vasa vasorum must  not
always be  looked for in acute aortitis;  for
although Hodgson and others speak of it
as a common anatomical character  of the
disease, Bouillaud remarks, that he had
only observed it in one instance out of a
great number,  and in that  it was  lim-
ited  to  a  small space, and  had the  ap-
pearance of being connected with  an ac-
cidental formation. (Diet, de Med. et Chir.
Prat. HI. 194.)  When this injection ex-
ists, it is most conspicuous in the cellular
coat if  the inflammation affect all the tu-
nics of the artery.  It is not so evident in
the fibrous coat;  but a delicate plexus of
minute vessels is sometimes observed, oc-
cupying the space between this tunic and
the lining membrane.
  Redness of the lining membrane does
not exist in chronic aortitis.   That tissue
is, on the contrary, of a dull  yellow, gray-
ish,  or  of a  green  appearance,—much
variegated,  however, by  the  diversified
shades exhibited in the  several textural
alterations which exist in  the coats of the
vessel.
  Alterations  of  texture and secretion
furnish much more unequivocal evidences
of the existence of inflammation in the ar-
terial tunics, than simple redness. Hence,
Laennec,  Mondovi,  and nearly all the
most modern  pathologists, only consider
that redness inflammatory, which is either
associated with  some sensible  structural
modification of the tissues of the  vessel,
or the deposition of lymph  or pus within
the cavity of the artery, or in  the substance
of its tunics.
  Softening of the coats  of the artery is
an  early  effect of  inflammation.   The
lining membrane becomes soft and spongy,
and loses its natural polished appearance.
Portal describes the case of a youth, who
died in consequence of the repulsion of an
exanthematous eruption, in whose body he
found the  internal membrane of the aor-
ta red,  tumid, and  preternaturally soft.
(Anat. Medicale, III. 127.)  It can gene-
rally be detached  from the  fibrous tunic
with great facility; and in some instances
presents a slight villous appearance, simi-
lar  to that exhibited by inflamed  serous
membranes.  The fibrous coat becomes
remarkably fragile,  and  is  partially or
completely  divested  of  its   elasticity.
Softening likewise takes place to a limit-
ed extent in the cellular coat, which, at
the  same  time,  loses its  natural pliabil-
ity, but still remains somewhat resistant.
It is, nevertheless, more yielding  in this
state than  in  its healthy  condition; and
this cause, co-operating with the diminish-
ed cohesiveness  of the  other tunics,  is
doubtless  instrumental in giving rise  to
the preternatural dilatations of the aorta
which are so  often observed.   There is
likewise great fragility of the coats of the
aorta, when they are affected with chronic
inflammation.  Although more dense than
in their natural state, they are so inordi-
nately brittle,  especially the middle coat
as to be easily lacerated. 
AORTA. (Inflammation, and its results.)                 155
  Induration is not often observed as an
immediate consequence of acute aortitis:
the chronic form of the disease, however,
is very generally attended with this patho-
logical state of the tunics of the artery.
Still, the fibrous coat though thinner and
more rigid than in health, is preternatu-
rally brittle, while the cellular coat  loses
its  filamentous texture, becomes denser
and more resistant and frequently under-
goes important changes in its nutrition,
by  which various new products are de-
veloped, of which we shall speak under a
separate head.
  With either softening or induration there
may be associated increased thickness of
the coats of the vessel, constituting a spe-
cies of hypertrophy; or they may be more
or  less attenuated, or atrophied.  These
several pathological states may be con-
fined either to a small portion of the aorta,
or they may implicate the vessel to a great
extent; and, very often, two or more of
them are found associated,—different por-
tions of the vessel being affected dissimi-
larly.
   Ulceration of  the  aorta is  very  com-
monly a consequence of chronic aortitis;
but the acute form of the disease probably
seldom gives rise to  it.  The ulcerative
process often occasions superficial erosions,
which are confined to the lining membrane,
and give it a rough appearance. In a num-
ber of instances, ulcers, variable as to their
depth and extent are formed, which ter-
minate by well-defined borders.  Some of
them are not  larger than  a  pin's  head,
while others are half an inch or more in
extent.  In those which are most superfi-
cial, the base is formed by the fibrous coat
of the vessel; but sometimes this tunic is
also destroyed,  and the cellular alone  pre-
vents the blood from escaping.  The  bot-
tom of the ulcer is rough, and is either
covered by a small layer of coagulum, or
a kind of darkish-coloured pellicle, which
adheres to its  surface.  When the  two
inner coats of the artery are destroyed by
an ulcer, the external  generally becomes
dilated at the point affected, and aneurism
is induced; or  it is destroyed in its turn,
and a complete perforation and sudden
death are the consequences.  As regards
the number and extent of the ulcers, much
will depend upon the extent of the vessel
that is inflamed.  In some instances, there
may be a single one, or only a small num-
ber, sparsely arranged.   Yet cases some-
times occur, in  which they are exceeding-
ly numerous, and occupy nearly the whole
length of  the aorta.   A case of this  kind
has  been  reported  by Meckel, (Grand-
father,) in which the aorta, from a small
distance above the semilunar  valves, to
the iliacs, was most extensively ulcerated,
and its internal coat which exhibited  a
lacerated appearance, was detached at
several points, and floated within the ves-
sel.  (Mem. de VAcad. des Sc.  de Berlin.
XII. 1756. Diet, de Med.) Andral like-
wise remarks, that he witnessed a case in
which the internal surface of the  whole
extent of the thoracic and abdominal aor-
ta was occupied by numerous small round-
ed ulcers, the medium size of which, was
that of a five-cent piece.   They were so
superficial as to be  with difficulty per-
ceived, and the borders of some of them
were surrounded by a brownish rose-co-
loured  circle.  There  was  no  ossifica-
tion of the coats of the  artery.  (Precis
oVAnat. Path. II. 358.)  We  have often
observed ulcers of variable size in  differ-
ent portions of the  aorta, and in some in-
stances, the lining membrane  of the ves-
sel has been detached in the vicinity of
the ulcer to some  extent, so as to  suffer
the blood to become slightly  insinuated
beneath it.
   Ulceration of the aorta may  take place
in the  same manner as  in other tissues.
In most cases, however,  the  manner in
which it is induced is somewhat different.
The ossific or calcareous plates, which so
frequently form beneath the lining  mem-
brane, often  detach it  from the fibrous
coat,  and finally lacerate  it,   or project
through it so as to be placed in immedi-
ate contact with the blood.   These  scales
are occasionally detached in this manner,
and the bed  they previously occupied is
transformed into an ulcer. In other  cases,
the small atheromatous, tuberculous,  and
other deposits, which so  often form  be-
tween the internal and  middle coats of
the artery, give rise  to a destruction of
the former, and become  converted into
small ulcers.  It is probably in this way
that a large majority of them  have their
origin, though it should be remarked, that
they may also proceed from the rupture
of small abscesses.
  Ulceration of the aorta  may, besides,
take  place  externally, and advance  in-
wards.  When this is the case,  the ulcer-
ative  process  originates in some disease
situated in the vicinity of the vessel, and
gradually exercises its ravages, so  far as
the latter is concerned, first upon the cel-
lular  coat and subsequently upon  those
which are deeper seated.   We shall have
occasion to speak of a rare form of  aneu-
rism, which is sometimes induced in this
way;  but a much more  frequent conse- 
156
AORTA.  (Inflammation, and its results.)
quence of this excentric ulceration, is, the
development  of perforations,  sometunes
establishing communications between the
aorta  and the trachea, bronchi, oesopha-
gus, lungs, &c. (See § 4, and § 7.)  It is
not easy to determine whether  ulcers of
the aorta cicatrize, like those affecting
other tissues.  Bouillaud seems inclined
to think they are  capable of undergoing
this change.   Hence he infers, that the
small  puckered  depressions which are
sometimes observed occupying  the inter-
nal surface of the vessel, in connexion
with  other symptoms of chronic aortitis,
are cicatrices, indicating the site of ulcers
which have healed.
  The effusion of plastic lymph within the
vessel, or in the  substance of its tunics,
and the formation of pseudo-membranous
deposits  upon the  surface of the  lining
membrane, are characters of aortitis that
cannot  be mistaken, when they  occur.
These deposits would be oftener met with,
were it not that the lymph is borne along
by  the  stream of blood as soon as  it is
poured out, and is thus prevented from
accumulating and adhering to the lining
membrane.   Sometimes  the lymph is de-
posited  in small quantity, and merely ad-
heres to the coat of the artery in form of
a soft gelatinous pulp, (mollis succus pul-
taceus, Haller,) which can be wiped off
with very slight force.   In other cases, it
forms shreds, flocculi, bands,  or even a
continuous membrane, of considerable ex-
tent and thickness, which adheres closely
to the original tissue. These pseudo-mem-
branes may occupy the vessel  to the  ex-
tent of several inches, or be confined  to
one or more small  points: they  also form,
occasionally,  masses of so large a size, as
to encroach considerably  upon the caliber
of the artery, and impede the transmission
of the blood through it.   Examples of the
arrangement last described, have been no-
ticed by Boerhaave, De Haen, Spangen-
berg, Burns, Bertin and Bouillaud, &o.;
and others will be found reported in the
Eph. Nat. Curios. Dec. I. obs. 18. Dec. III.
85.   Act. Nat. Curios. X. obs. 95.   Nov.
Act. N. Curios. VII. obs. 37.  Morgagni,
Epist. XXXVIII. 40.  Klauning, Nosoc.
Charitat. Hist. 4. and 22.  Patin,  Epist.
de  Aorta  polypose, 1731;  and Joseph
Prank, Praxeos Medica Precept. II. part
2. 300.   Other examples will be referred
to,  when we treat of obstruction and oblit-
eration of the aorta.  Cases in which the
adventitious lymph deposits were less con-
siderable, and presented the  characters
first described, have been noticed by Hal-
ler, J. P. Frank, Bertin and Bouillaud,
Spangenberg, Monoovi,  Burns,  Farre,
Kreysig,  Hodgson,  Gendrin,  Barde,
Hope, S. Jackson, and many others, whose
names it is unnecessary to enumerate.
  Suppuration is probably a rare attendant
or consequence  of inflammation of the
aorta, as it has not been often observed.
Well authenticated cases have, neverthe-
less, been reported, from which it appears,
that the matter may be poured out from
the arterial tunics, either with or without
abrasion, or be collected  into  small ab-
scesses, which occupy the space between
them.   Monro has made some remarks
(Edinburgh Med. Essays, Vol. II.) on the
formation of purulent matter by the inter-
nal surface of the arteries; and Welch
has described the  case of a female, who
died suddenly, under the influence of a fit
of anger, in whose body he found two ab-
scesses occupying the aorta, in the vicini-
ty of the heart, through which the blood
had been  extravasated, so as to occasion
her death.  (Lieutaud, Hist. Anat. Med.
Lib. II. obs. 667.) Storck found the aorta,
to the extent of an inch from its origin, as
well as  the heart itself, in a state of sup-
puration.  (Ibid. obs. 517.)   Weitbricht
has also described a  case  in which the
vessel at its origin was in the same state.
(Comment. Petrop. IV. 263.)  The most
satisfactory case, however, is one reported
by Andral.  The  lining membrane  was
elevated at different  points,  by  half a
dozen small abscesses of the volume of a
small nut which were situated between
the serous and fibrous coats of the vessel.
The matter they contained  resembled the
pus of an ordinary phlegmonous abscess.
(Op. Cit. II. 379.)   Lobstein also reports
a case, in which he observed small cavi-
ties of a yellowish straw-colour,  occupy-
ing the  internal surface of an aorta which
was affected with aneurism. When open-
ed, they discharged a few drops of pus, of
the colour and consistence of thin cream.
(Traite de Anat. Path. II. 544.)  Allusion
is  made to a similar condition, by Hodg-
son.  Such collections naturally  tend to
destroy the thin lining membrane which
is interposed between them and the blood,
and thus escape  into the artery.   When
this event takes place, the remaining cav-
ity is apt to be converted into an ulcer, as
we have already explained.
   Atheromatous secretions  are  of more
frequent occurrence.   The most simple
form in  which they appear, is that of small
yellowish  points, which elevate the lining
membrane, and project into the cavity of
the vessel, like minute pustules.  These
elevation? consist of small collections of a 
AORTA. (Inflammation, and its results.)
157
 peculiar matter, exceedingly variable  in
 its consistence ; being in some cases per-
 fectly fluid and resembling thin pap, but
 occasionally of a thicker consistence, and
 somewhat  curdy,  or  like  the matter
 which  is  discharged from  a scrofulous
 abscess.  Such collections are formed at
 first between  the  internal  and middle
 Qoat of the artery, but as they increase in
 size, they impair the  structure of both,
 finally destroy the  former,  and  become
 converted into small  ulcers of the charac-
 ter we have already described.  The pre-
 cise nature of these secretions, which are
 so often met with in  the tunics of the ar-
 tery, has not been satisfactorily ascertain-
 ed.  By  some, the  matter  denominated
 atheroma, has been considered merely as
 a  modification  of tuberculous secretion,
 and several pathologists regard both as the
 inceptive stage of the calcareous transform-
 ation.  In corroboration of this view, they
 affirm that these deposits seldom exist to
 a great extent, without being associated
 with more or less ossification of the coats
 of the  vessel.   Be this as it may,  they
 often lay the foundation  of aneurism,  by
 gradually destroying the serous and fibrous
 coats of  the artery,  merely leaving the
 cellular or external  to sustain  the  onus
 of the  circulation.  Their importance  in
 this respect, was clearly pointed out  by
. Scarpa, and has been fully acknowledged
 since his time.  (See  Aneurism.)
   Tumours. Adventitious developments, in
 form of irregular masses of variable mag-
 nitude and consistence, have been described
 as occasionally occupying the coats of the
 aorta.  By some of  the  earlier  writers,
 they were denominated  polypus, and  in
 more modern times,  some of them have
 been described under the appellation  of
 steatomatous tumours.  Examples of this
 kind  have  been  already  referred   to,
 especially the cases reported by De Haen,
 Patin, and in various parts of the Epher-
 meredes.   Stenzel  has  particularly de-
 scribed a  similar tumour  of the arch  of
 the aorta, which was white and  compact
 externally, and contained within, a firm
 sebaceous and adipose  substance.   (Dis-
 sert, de Steatom. Aorta.  1723.  Guth-
 rie, p. 34.)  The aorta was so much dis-
 tended by the tumour, as to nearly  equal
 the heart  in volume,  and  its  caliber was
 so greatly diminished, that the blood  could
 with difficulty pass through the vessel.  A
 case has likewise been reported by Pietro
 Paulo dclPArme, in  which a tumour was
found near the orifice of the aorta, which
had its origin between  the tunics of the
artery, and completely filled up its cavity.
   VOL. 11.           14
When cut open, a  quantity of purulent
matter  escaped,  equal  to  several  small
spoonfuls. (Saggi, di Med. Practica, con
note di Borsieri, Obs. 35.  Faenza, 1768.
Frank, 302.)  We may also refer to two
cases observed by Corvisart, which pos-
sess considerable analogy with some of
those to which  allusion has been  made.
In  one of these, a tumour as large  as a
walnut, and of a firm consistence, adhered
to the arch of the aorta.  It was surrounded
by a firm fibrous membrane of two lines in
thickness, which included  a substance of
a red colour, not quite so consistent as tal-
low.  No communication could be disco-
vered between the interior of the tumour
and the cavity of the vessel,—the outer
coat of the latter being destroyed, while
the others were  only a  little attenuated.
A similar tumour, somewhat smaller, was
discovered a little above the cceliac artery.
In  another case, he saw two or three tu-
mours of the  same kind adhering  to the
ventral aorta.  (Essay on the organic dis-
eases of the  heart and great vessels, p.
242.  Am. edit.  Philada.  1812.)  Since
that period,  similar tumours  have  been
several times noticed by different individu-
als, and especially by Hodgson and Guth-
rie.  The former, however, thinks they
are merely aortal aneurisms which have
become spontaneously cured; and in this
sentiment he  is  followed by a majority of
the most recent writers.  Guthrie, never-
theless, while he admits that this may be
the case, seems  inclined to concur with
Corvisart, in regarding them as of a dif-
ferent nature. Whatever view be adopted
in reference to these particular cases, it is
certainly true, that small vegetations and
tumours do sometimes  spring from the
coats of the  aorta,  and project  into its
cavity.   They seldom,  however, present
a proper steatomatous character, but vary
so much in their structure, that  it is not
easy to apply to them,  collectively,  any
appellation calculated  to convey a clear
idea of their nature.
  Cartilaginous and osseous, or  rather
calcareous, transformations, are the most
common morbid  changes to which the tis-
sues composing the aorta are liable.  The
extent to which they exist  is exceedingly
variable.  Sometimes merely consisting
of a few minute isolated points of a yel-
lowish colour, they frequently form large
plates  or scales,  embedded between the
serous and fibrous coats of the artery, and
occasionally converting the whole  circum-
ference of the vessel into a rigid  carti-
laginous, or  calcareous  cylinder.  Very
frequently the earthy scales destroy the 
158                   AORTA.  (Inflammation, Symptoms.)
lining  membrane, and have ene  of their
margins  projecting into  the artery; and
sometimes they  become  completely  de-
tached, as has been previously remarked.
Cartilaginous plates  often alternate with
such as  are of an earthy character, and
the whole inner  surface of the  affected
portion of the vessel presents  an uneven
rugged appearance, the lining membrane
being either destroyed at points,  exhibit-
ing numerous cracks  or fissures, or mate-
rially altered In its properties.   These le-
sions, however, are so common throughout
the whole arterial system, that  they can
be better described under the head Arte-
ries, and need not be particularly consi-
dered in  this place. It may, nevertheless,
be proper to remark, that the  term ossifi-
cation, which has been generally employed
to express the manner in which  they are
formed, is not appropriate, as the calcare-
ous crusts are rather the result of a spe-
cies of crystallization of the earthy matter
poured out by the diseased vessels, than
of a process analogous to that by which
bone is formed.   When these  transforma-
tions exist even  to a  limited  oxtent, the
elasticity of the vessel is greatly impaired,
and when they are extensive, it is com-
pletely destroyed, while the tunics them-
selves  become so friable and brittle, that
they yield under  the application of very
slight force.  The calcareous  transforma-
tions sometimes attain a very great size,
and either exist  in form of broad flatten-
ed  plates,  or  of  thick,  rugged, uneven
masses.   Tulpius reports a case,  in
which  he found a fragment of this kind
occupying the aorta, which weighed two
drachms  (Obs. Med.  Lib. II. cap. xxv.  p.
134. tab.  vi.); and examples are not want-
ing, in which the coats of the  vessel have
become so loaded  with this species of mor-
bid crystallization, as to be converted into
firm unyielding cylinders, remaining per-
fectly  passive  as  regards the  circulation
of the blood. In all cases, they have their
origin in  the very delicate cellular or fila-
mentous  tissue which serves as  the bond
of union  between the internal  and middle
coats of  the aorta, and not in the lining
membrane as was formerly supposed. The
question relative to their dependence upon
chronic  inflammation, is a point which
will be discussed  under the head Arteries.
  Cancerous or encephaloid degeneration
of the aorta is probably of rare occurrence.
Laennec, nevertheless, remarks, that he
has occasionally discovered small particles
of this morbid  product deposited  in the
cellular coat of the aorta.  (Auscultation
Mediate.  U. 684.)
  It may be supposed by some, that there
is no valid reason for treating of all these
lesions under the head of inflammation of
the aorta.  It is possible that some of them
may arise from  other causes.   Yet as in
the present state of our pathological know-
ledge, this question cannot be decided, we
have thought  it better to group them all
under one  head, than to make a multipli-
city of divisions of the  subject.
  Symptoms and Diagnosis.  There is
perhaps no disease, the symptoms  and di-
agnosis of which are more difficult  and
uncertain, than those of aortitis. The deed
situation of the vessel, its intimate and ex-
tensive relations with so many organs, and
the extreme  difficulty there is in distin-
guishing those  phenomena produced by
the action of  the aorta,  from such as
are attributable to derangements of the
heart's action, render it almost impossible
to determine with certainty the existence
of this disease, or to discriminate between
it  and other affections.   Joseph Frank,
who has witnessed the disease in its acute
form, and who has furnished a very good
digest of the observations made by others
relative to its phenomena, has given a full
enumeration  of  the  different  symptoms
which  have  been witnessed  during  its
progress.  They are " increased heat  and
redness, with great itching of the skin;
pain of the head and extremities; flushing
of the face; ringing of the ears; increased
brilliancy of the eyes, with rolling of the
balls; epistaxis; dryness of the mouth and
tongue,  with urgent thirst; difficulty of
deglutition; a sense of heat beneath the
sternum, or above its triangular notch; a
feeling  of  burning, like  that occasioned
by a hot iron,  extending along  the whole
tract of the aorta, even down to the iliacs;
vertigo and clouded vision, or objects ap-
pearing of a green colour; a disposition
to syncope from slight exertion, or when
the body is in  the erect  posture; a vi-
bratory pulsation of the  carotids,  and of
the arteries  of the whole system;  the
pulse frequent  sometimes intermittent
hard and  chorded, imparting the sensa-
tion of a metallic wire beneath the finger;
turgescence of the superficial veins; op-
pressed  breathing; jactitation,  and great
anxiety; the urine scanty, scalding, very
high coloured, depositing a copious sedi-
ment, and  sometimes purulent; palpita-
tion of the heart, cough, vomiting, diar-
rhoea, and subsultus tendinum.  The dis-
ease either continues in  its  course, or
exacerbating,  is  generally  protracted to
the  seventh  day, when  it  terminates
in health  or becomes chronic; or death 
AORTA. (Inflammation—Causes.)
159
ensues.   The crisis generally takes place
by a free perspiration; but when the mal-
ady assumes a fatal turn, the extremities
become cold, while the internal parts are
affected with the sensation of a consuming
heat; the pulse fails, and death ensues."
(Praxeos Medica  Univers. Precept.  II.
pars. 2.  p. 297.   Lips. -1824.)
  A glance at these symptoms will show
how inadequate  they are  to distinguish
the disease.  There  is  not one of them
that is not  common to  many other affec-
tions ;  and several of them would apply
as well to any other disease,  as to inflam-
mation of the aorta. J. P. Frank thought
the  peculiar  hard, tense,  and  chorded
pulse characterized the disease with more
certainty than any other  symptom; but
we are disposed to concur with Bouillaud,
in regarding an augmented activity of the
pulsations of the aorta, a sense of heat and
uneasiness in the  course of that vessel,
a feeling of great anxiety, and a disposi-
tion to  syncope such as occurs in many
affections of the heart more entitled to
confidence.  (Diet, de Med. et de Chir.
Prat.  III. 179.)   But even  these symp-
toms are observed in acute  pericarditis
and some other diseases  of the organs of
circulation, and cannot justify a positive
conclusion.   The stethoscope will gene-
rally enable us to distinguish  the pulsa-
tions which attend this disease, from those
occasioned by an aneurism, and a careful
examination of the abdominal aorta will
sometimes  facilitate the formation  of  a
correct diagnosis.   It must not be forgot-
ten, however,  that effusions of water in
the cavity of the thorax and abdomen, the
development of tumours in the course of
the aorta, the distension  of the intestines
with gas, &c,  will tend to render the
pulsations of the vessel  more perceptible
than they would be under other circum-
stances.   Should, however, all these con-
ditions be absent, while  there are violent
pulsations,  and  a  sense of  heat in the
course of the  vessel; throbbings of the
arteries  generally;  turgescence of the
veins; redness and heat of the skin, and
general uneasiness, with a liability to syn-
cope on  the slightest exertion,  we  may
reasonably suspect the existence  of  acute
aortal inflammation, especially if pericar-
ditis, aneurism,  or hypertrophy of the left
ventricle of the heart be not indicated by
the ordinary physical and rational signs.
J. P Frank supposed that acute  arterial
inflammation was the  essential patholo-
gical condition of the common inflamma-
tory fever:—an opinion which many have
adopted since his time.   We shall not dis-
cuss the validity of this hypothesis in the
present place, as it can be more appropri-
ately considered under the head of patho-
logy of the arteries.
  The symptoms  of chronic aortitis are
still more equivocal.  The disease seldom
creates so much disturbance as to awaken
a suspicion  of its  existence, untd it has
made considerable progress, and even then
its principal symptoms, according to  Bou-
illaud, are merely such as result from a
mechanical obstacle to the  free transmis-
sion of the blood.   The  individual  fre-
quently experiences a difficulty of respira-
tion, or exhaustion, on taking the slightest
exercise; the countenance is pale  and
sallow; the blood accumulates  in the left
ventricle, and excites frequent  palpita-
tions;  the  cavities of the  heart  become
dilated or hypertrophied, and serous  effu-
sions finally take place. (Bouillaud. Loc.
Cit.) If these symptoms exist when there
are no evidences of disease at the orifices
of the heart, or  none of aneurism of the
aorta, there will be reason to fear the ex-
istence of  important  alterations of the
structures which compose that  vessel.
   Causes.  The causes of inflammation
of the aorta may be divided into trauma-
tic, as injuries of various kinds, and such
as give rise to inflammation of other in-
ternal organs.  It may be excited by vio-
lent passions  of the mind; preternatural
exercise too long continued; the excessive
use of acid or stimulating drinks; the
operation of cold upon the surface of the
body, &c.   In one of the  cases reported
by J. P. Frank, the disease was brought
on by  the violent exercise  which the in-
dividual was forced to take, in attempting
to fly from justice,  for the crime of homi-
cide ;  and Joseph Frank met with a case
in which it was excited by taking a copi-
ous draught of vinegar by mistake, instead
of water.  The disease  is probably often
induced by the imprudent use of mercury;
and there arta certain affections of the sys-
tem, as gout scrofula, scorbutis, syphilis,
&c, which have a great  tendency to ex-
cite chronic  inflammation  of the  aorta.
(Kreysig.   Krankheiten  des Herzens.
 The.il. II. 747.  Hodgson.  Loc.  Cit.)
   Treatment.  As little is known, unfor-
tunately, of the treatment of  aortitis,  as
of its symptoms and diagnosis.   In  the
acute form  of the disease, general princi-
ples indicate the necessity of free abstrac-
tion of blood, both by the lancet, and by
leeches  applied along the course of the
aorta.  This practice is imperatively de-
manded, whenever the momentum  of the
aortal circulation is greatly increased, and 
160                  AORTA. (Inflammation—Treatment.)
it must be repeated as often as necessity
may demand, care being always taken to
regulate the quantity by the capability of
the system to endure it.  It should never-
theless be borne in mind,  that  inflamma-
tion of the aorta, and  of the arterial sys-
tem generally,  sometimes takes place in
the course of fevers  of a malignant or
ataxic  character.   Under such  circum-
stances, the abstraction of blood can  sel-
dom be resorted to.   The patient should
be  confined to a strict antiphlogistic regi-
men ;—be allowed bland, cooling, and re-
freshing drinks, mild saline aperients,  and
in short all the usual means for diminish-
ing preternatural activity of the heart and
arteries.   In addition to depletion, it may
be useful to administer digitalis in such a
manner as to obtain  its  influence upon
the circulation.  The system may be kept
under its control for some time, care being
taken not to push the dose too far. Prussic
acid in small doses repeated according to
circumstances, may likewise  prove bene-
ficial, when the inflammation is associated
with preternatural nervous erethism, char-
acterized by a peculiar irritable thrill of
the pulse,  and  that state of the nervous
system which  exists under such circum-
stances.  Paginini speaks favourably of a
bath, containing  four ounces  of aqua
Amygdala? amarae, or aqua Lauro-cerasi,—
the  strength to be gradually increased;
also of baths  of aconitum, cicuta, hyoscy-
amus, &c. (Annali  Universali di Med.
1826.)  They are only applicable to the
chronic forms of the  disease;  and under
the  same circumstances,  alkaline  baths,
containing opium  in  solution, have been
recommended. (Naumann.  Handbuch der
Medicinischen  Klinik.  II. 775.   Berlin,
1830.)  Great care must be taken  not to
resort  to  active revulsives too early, lest
by  increasing the  excitement of the  sys-
tem, they should augment the local affec-
tion.   When they are proper  even, blis-
ters will  often be found  too stimulating
and must  be resorted to with  caution.
Generally, pustulation with tartar emetic
ointment  will  deserve the  preference.
Every source of excitement must be most
scrupulously avoided,  and this will be not
less important as regards those of a men-
tal  character, than such  as  act through
different channels.
  Chronic aortitis being infinitely variable
in its general symptoms, and the charac-
ter of the organic  lesions it  occasions,
must be treated upon  general  principles.
When congestions take place  in the left
ventricle  of the heart giving rise to  pal-
pitations and other disturbances of circu-
lation, small abstractions of blood must be
made, either by the lancet or an adequate
number of leeches.  Repose of both mind
and body should  be  enjoined,  and every
source  of irritation carefully  avoided.
When the disease  has  continued for  a
long time, and is attended with a general
impairment  of the nutritive energies,  a
different treatment may become necessary.
Under such circumstances, it may be use-
ful  to put the patient upon  a course of
chalybeate remedies,—in  mild weather,
the cold shower-bath,—and to recommend
the employment of some appropriate min-
eral waters.   It  must not be  concealed,
however, that all treatment in  such cases
must be merely palliative, and  can effect
little  more than a temporary  mitigation
of immediate  symptoms,  or  prevent the
development   of  those  consequences,  to
which the disease is  so apt to give rise.
  Aortitis which takes place  as a compli-
cation of other diseases, must be treated
on  general  principles.   When it  arises
from  syphilis, it has been  supposed by
some that mercury will be the most ap-
propriate remedy.  It should be remem-
bered, however, that  the disease is often
excited by that article,  and  may be ag-
gravated  by its influence.
  Of erysipelatous  inflammation of the
aorta we shall not speak,  farther than to
remark, that it may sometimes exist. We
know nothing of its proper symptoms, and
cannot distinguish it during life.
  For Bibliography, see  Arteritis.
  § 2. Constriction  and obliteration of
the Aorta.  Constriction and  partial ob-
struction of the aorta may take place from
different causes, and when they exist in a
considerable degree,  occasion serious em-
barrassment of the circulation, by inter-
rupting the free transmission of the blood.
A considerable diminution sometimes takes
place in the calibre of the vessel, in those
protracted diseases  which are  attended
with  great emaciation  and an imperfect
supply of blood, as in anemia, phthisis, &c.
This, however, is merely a  consequence
of enfeebled  nutrition,  and does not de-
serve particular attention. More frequent-
ly,  constriction and partial obstruction de-
pend either upon extensive  pathological
changes of texture,  taking place  in the
coats of the  vessel,  morbid  growths oc-
curring in its  cavities, or tumours, which
have their origin from without, encroach-
ing upon its walls.   When inflammation
affects these  structures, plastic lymph  is
often so freely deposited in their meshes,
or interstices,  as to occasion a great  in-
crease of thickness, which,  encroaching 
AORTA. (Constriction and Obliteration.)
161
upon the calibre  of the vessel, constricts
its diameter, and where it is still more
considerable, may give rise to a total ob-
literation.  The tunics of the aorta are
here thick and indurated, and present but
few or  none of their  natural properties.
They are, indeed, often converted into a
compact texture,' highly resistant, and al-
most fibrous in its character. The exten-
sive deposits  of  lymph  described above,
which  sometimes form  upon  the inner
surface of the vessel,  and  become organ-
ized, may in like manner occasion obstruc-
tion, either partial or  complete.  This is
the  case with the numerous tumours to
which  allusion  has  already been  made,
under the appellation of polypus, and ste-
atomatous  tumours of the aorta.  They
sometimes so nearly fill up the  cavity of
the vessel, as to leave but little space for
the blood to pass, and occasionally, they
obstruct it entirely, and finally give rise
to complete obliteration.  The same effect
is sometimes produced by the  extensive
calcareous deposits  which  form in  the
coats of the artery.    They may attain so
great a size, as nearly to  interrupt  the
transmission of the blood along the course
of the  artery, or in  proportion  as these
transformations take' place, the size of the
vessel may become merely narrowed, with-
out the new development forming any con-
siderable projection in the manner alluded
to.  The aorta is probably  not often  ob-
structed by tumours which are  forfhed in
the tissues  situated  in its  vicinity;  yet
such an accident sometimes occurs.  In
some instances the aorta is also obstructed
by fibrinous  concretions  formed  by  the
blood, which become more or less inti-
mately attached to the internal surface of
the artery,  and eventually acquire  the
firm consistence possessed by  the lamel-
lated structure which forms  within  an
aneurismal sac.
   There is  still another species of con-
striction or obliteration, which  is not at-
tended with any very manifest  alteration
of texture.   The vessel presents a nar-
rowed  or  constricted  appearance, at  the
point affected, as though the circular fibres
were preternaturally  contracted.   There
is no  thickening of its tunics, but they
present their healthy appearance, and  are
merely so much contracted  in  a circular
direction, as  to occasion a slight diminu-
tion of the calibre of the  artery;  or  the
tube may be completely closed up and ob-
1 iterated.  Most of these cases are proba-
bly congenital, and arise from  zn imper-
fect evolution of the  affected portion of
the vessel; but it is possible that a similar
                  14*
change  may be  gradually acquired, by
some  irregular action taking place in the
fibrous coat of the artery.
  Cases of partial obstruction of the aorta,
from the development of morbid growths,
are so numerous, that we  shall not pre-
tend  to refer to all those  which  are on
record. Many of the cases already quoted,
of  tumours  affecting its  coats,  belong
properly  to this  head,  and need  not be
cited  a second time.   Morgagni reports
a case, in which the  aorta,  from  the
arch  to the  origin of the emulgent ar-
teries, was reduced  to  the  size  of the
finger.  (Epist. XXX.  12.)   Sandifort
(Obs. Anat. Path. II. Obs. 10.), Meckel
(Mem. de VAcad, de Berlin. 1756.  p. 61.),
and Monro  (Medical Essays.  II. 237.),
have  reported  cases in which the vessel
was obstructed by irregular tumours, which
were attached to its tunics.  Other exam-
ples of partial  obstruction  have been re-
corded by Morand (Mem. de. TAcad.  Roy-
ale de Paris. 1736.)  and Brasdor.  (jRe-
cueil Periodique. III. No. 18.)  In Mo-
rand's case, the disease originated from a
contusion of the abdomen.
   More recently, a  number of examples
of this pathological  state have been ob-
served by different   individuals.  In the
body  of an old woman, which Paris in-
jected for  anatomical purposes, in 1789,
he found  the aorta,  immediately  beyond
the arch, contracted to the size of a wri-
ting-quill.  The vessel above the constric-
tion  was dilated, as were likewise the
trunks which  arise  from  the arch,  and
their branches.  The coats  of the  aorta
were of their  proper thickness, and the
circulation had been carried on through
the anastomoses of the collateral branches,
which were greatly dilated, and tortuous.
(Desault.   Journal de Chirurgie.  II.
108.)  The case  of a  young man, who had
been affected  with great oppression and
palpitation, is described (Journal de  Med.
XXXIII.  1815.), in whose body the arch
of the aorta was dilated to the diameter of
nearly four inches, and the vessels which
proceed from the affected portion were also
so much increased in size, that the left sub-
clavian seemed to be  the continuation  of
the aorta.  The descending portion of this
latter vessel was diminished in its  diame-
ter to about four-fifths of an inch, and six
or seven lines below the origin of the left
subclavian, it was entirely obliterated, to
the extent of  a  few lines.  The  ductus
arteriosus was open, and was large enough
to receive  an ordinary catheter.  An ex-
ample somewhat analogous  to this has
been described  by Dr. Graham.  (Medico- 
162
AORTA. (Constriction and Obliteration.)
 Chirurgical Trans. V. 287.)  The aorta,
 near its origin, was expanded like a pouch;
 but  after giving off" the branches to the
 head and upper extremities, its diameter
 was contracted. A little beyond its union
 with the ductus arteriosus, it was  com-
 pletely obliterated, although there was no
 thickening or disease  of its coats, except
 that about half an inch below  the stric-
 ture, there was a smooth elevation of the
 inner surface, having nearly the diameter
 of a split pea, but not so much raised. The
 stricture presented the appearance which
 would be produced by  the application of a
 ligature to  the  vessel, and above it, the
 orifices of three  intercostal arteries,  di-
 lated to the size of a crow-quill, were dis-
 covered  communicating  with the  aorta.
 The subject of the case was a youth, aged
 fourteen years, who died of an affection
 of the chest.
   In a case observed by Winstone  and
 Sir A. Cooper,  the constriction existed
 near the  same point, but did not amount
 toi a total closure  of the  aorta,  which, at
 the strictured point, was large  enough to
 receive the tip of the little finger.  The
 circular  fibres of  the  vessel were some-
 what thickened,  and there were some
 traces  of calcareous transformation.  The
 individual was fifty-seven years old,  and
 had enjoyed good health, except in winter,
 when he suffered much from an obstinate
 cough.  His deatli was  occasioned  by a
 rupture of the left ventricle of the heart
 induced no  doubt  by the constriction of
 the aorta. (Cooper and Travers. Surg.
 Essays. Vol. I.)  A. Meckel has likewise
 published a very interesting case, in which
 the aorta, near the ductus arteriosus, was
 reduced to the size of a common straw. It-
 occurred  in a peasant at Berne, who had
 enjoyed good health, but  was seized  sud-
 denly,  while carrying a sack of corn, with
 extreme weakness, which rendered him
 unable to  proceed.   He was conveyed to
 the hospital, where he apparently reco-
 vered his  health, but afterwards  died sud-
 denly,  while seated by the stove.   The
collateral  vessels were found enormously
dilated, and  resembled  varicose veins.
 (Meckel's Archives fir Anat. und Phy-
siologic 1827. p. 34-"), and N. Amer. Ar-
chives of Med. and Surg. Sc.  I. p. 155.)
Another example of nearly the same kind
has been  recorded  by  Renaud.  (Journal
 Hebdomad, de Med. II. 161, and Ameri-
 can Journ. of Med. Sc. IV. 208.)  It oc-
curred  in a shoe-maker, aged ninety-two,
 who was  admitted into  La Charite,  in
 1817, in a very feeble  state.  The aorta,
which  for some distance from its origin
 presented its natural size, was somewhat
 narrowed  beyond the origin  of the inno-
 minata,  and  near the ductus arteriosus
 it presented a very considerable circular
 contraction, such as would be  produced by
 a ligature drawn very tight  Below this
 point it was enlarged, but in the abdomi-
 nal cavity it was  somewhat smaller than
 natural.   Mr. Nixon, of Dublin, has pub-
 lished a  case, which  may be referred to
 the same head.   The subject of it was a
 medical  gentleman, who,  after severe and
 protracted suffering, died anasarcous. The
 aorta, in its transverse portion, just at the
 point where  it is joined by the ductus ar-
 teriosus,  exhibited a  very singular con-
 striction, similar to what would occur if a
 sharp instrument  had been pressed upon
 its upper surface, until it had diminished
 the calibre by about one half.  There was
 no calcareous deposit in the coats of this
 portion of tiie vessel, and the  ductus arte-
 riosus was pervious.  (Dublin Journal of
 Med. and Chemic. Sc. No. XV.  p. 396.)
 The  same gentleman refers  to another
 case, reported by Jordan,  in the North of
 England Med. and  Surg. Journal, for
 1830.   The  heart was  found ruptured,
 and the constriction, which obliterated the
 aorta, was situated about three lines below
 the ductus arteriosus.  (lb. 389.)
   In  most of these cases, the texture of
 the arterial tunics was but slightly altered.
 In some of them, indeed,  no  appreciable
 alteration could be discovered. These ex-
 amples are, therefore, very different from
 such  as  are  a consequence of degenera-
 tions, and other changes taking place in
 the coats of the aorta. The annals of the
 science furnish numerous instances  of ob-
 struction  and obliteration from this latter
 cause.  One  of the most interesting, is
 that recorded by Goodison. (Dublin Hos-
pital  Reports.  II. 193.)   The aorta was
 obliterated from the origin of  the inferior
 mesenteric downwards, throughout the re-
 mainder  of its length, together with the
 greater part  of the iliacs, on  either side.
 It resembled the trachea in shape, being
 flattened posteriorly,  and  the  bony case-
 ment into which its  coats had been con-
 verted, was filled up with a compact fleshy
 substance, which had  the firm  appearance
 of the muscular fibre of the heart  In a
 case observed by Monro,  a large tumour,
 three inches in breadth, occupied the ab-
dominal  aorta at its bifurcation.   It was
 hard,  and of a whitish colour when cut.
 A little above it, the vessel was narrowed
and completely closed  by a conical phi?,
of a  firm consistence, which  adhered  to
each  side by dense layers of coagulable 
AORTA.  (Obstruction.)                        163
lymph.  This plug did not  seem to have
been formed in articulo mortis, but some
time before death, and probably by an in-
flammatory action of  the  vasa vasorum.
(Monro. On aneurism of the  abdominal
aorta,  p. 5.;  and Guthrie. Op. Cit.  p.
359.)
  A case of obstruction of the  abdominal
aorta from ossification, amounting almost
to complete  obliteration,  is recorded  in
Broussais' Journal.    The subject of it
was the count C, aged 67, who was a free
liver, and  who died of gangrene of the
feet,  induced by his habits and the dis-
eased state of the arterial system.  About
half an inch below the origin of the coeliac
artery,  the aorta was extensively ossified,
and  almost entirely obliterated.  There
were only two  small  passages  for  the
transmission  of the blood,  each of which
was not more than half a line in diameter.
The iliac arteries were also nearly oblite-
rated in several  places. (American Med.
Recorder.  XIV. 444.)  Another example,
in which the aorta was nearly  obliterated
at two  points,-—one above, the other be-
low the diaphragm,  has been reported by
Bright. (Reports of Medical Cases.) The
obstruction was  caused  by cauliflower-
shaped  masses of bony matter,  apparently
of rapid development   Cases  somewhat
analogous have been observed by Laennec
(Op. Cit.), Andral (Clinique Medicale.
II. 67.), Bouillaud (Loc.  Cit.), Dalmas
(Diet, de Med.  2d edit.  III.  400.),  and
many others.
  It has been remarked above, that can-
cerous degeneration  of the aorta is proba-
bly  of  rare  occurrence.   Velpeau has,
nevertheless, reported a very interesting
case of obliteration  of this vessel, taking
place, as he represents, in consequence of
the influence of a general cancerous dia-
thesis. The individual was a woman aged
thirty-six, who had  enjoyed good health
up to the age of thirty years. She became
affected at that period with a scirrhus tu-
mour,  which occupied the anterior and
lower part  of the arm.  It was twice re-
moved  by an operation, but was  finally
succeeded by cough  and embarrassed re-
spiration, from  which she died.   Scirrhus
depositions were found in the heart lungs,
pleura,  and most  of the abdominal organs.
The inferior  cava was occupied by a cy-
linder of a grayish colour and fibrous tex-
ture,  and  the aorta, below the third lum-
bar vertebra,  was filled with a cylinder of
a yellowish-gray  colour, in which was ob-
served a small  quantity of puriform mat-
ter. (Velpeau. Exposition <Tun cas re-
mfquable  de  maladie  cqncerevse avec
obliteration de Vaorle. Paris, 1825.  Medi-
co-Chirurgical Review. VII. 427.  1827.)
  It is somewhat remarkable, that in all
the cases we have cited, which were not
attended with considerable structural al-
terations of the coats of the aorta, occurred
in the immediate vicinity of the  union of
the ductus  arteriosus with that  vessel.
This point was the seat of stricture in the
cases reported by Paris, Corvisart, Win-
stone and Sir A. Cooper, Albert, Meck-
el, Renaud, Nixon, and Jordan. Another
interesting feature in two of these cases,
—those reported by Corvisart and Nix-
on, is, that the ductus arteriosus was found
open, and in one of them, was large enough
to receive a catheter. In all the others, it
is either described as being impervious, or
is not noticed.  The constancy of the con-
striction or obliteration at this point and
its  intimate relation  with the ductus arte-
riosus, together  with the absence  of any
very manifest thickening, or other altera-
tion of texture of the coats of the artery,
render it highly probable, that these cases,
or the majority of them at least had their
origin in a defective evolution of this por-
tion of the vascular system, owing to some
interruption or disturbance  of the  natural
process of development. This pathological
condition of the aorta, when  it presents
the characters which it did in the cases
referred to, may, therefore, be regarded as
of the same nature  as the examples  of
congenital atresia of different portions of
the alimentary canal, the urethra, vagina.
&c, which are so often observed.
   The other cases, however, are of a dif-
ferent nature.  They manifestly had their
origin in a diseased state of the coats  of
the aorta,  and  the  obliteration and  con-
striction were induced by the transforma-
tions of  which these structures were the
chief seat.
  In both classes of cases, the circulation
was carried on through the same collateral
channels.  The branches given off above
and below the point of obstruction, were
enormously dilated, and by  means of their
extensive anastomoses with each other,  a
sufficient quantity of blood was transmitted
through the numerous channels thus form-
ed, to compensate for the interruption  of
its course through the mam trunk.  Above,
the subclavians, the transverse  cervical,
supra-scapular, internal mammary, supe-
rior intercostal,  and  the thoracic arteries,
were generally found greatly dilated, and
presenting a tortuous appearance, analo-
gous to that exhibited by varicose veins.
Lower down, the intercostal, lumbar, cir-
cumflexus ilii, and epigastric arteries were 
164                          AORTA.   (Dilatation.)
found in the same condition; and the latter
especially, from its intimate anastomoses
with the  internal mammary artery, fur-
nished an  important channel for the trans-
mission of the blood.
  One would be disposed to infer, a priori,
that such  a state of the aorta must be ne-
cessarily productive of serious disturbance
of the  functions of the organs, and that it
could scarcely fail to  lead to fatal conse-
quences.  While such a conclusion is jus-
tified by the result of many cases, it is  in-
validated  by the phenomena of others.  In
some instances, the collateral circulation
has accommodated itself so readily to the
exigencies of the system, that little or no
inconvenience was experienced, and the
individuals enjoyed good health, and some
of them attained a considerable age. More
frequently,  however,  considerable func-
tional disturbance, and in some cases great
suffering,  were experienced. The obstacle
to the  passage of the blood gave  rise to
dilatation  and hypertrophy of the heart
frequent  palpitations,  dyspnoea,  conges-
tions of the lungs, with cough, haemopty-
sis, and effusions into  the pleura and peri-
cardium,—cerebral congestions, apoplexy,
and other affections of the brain. In some
of the  cases reported, the embarrassment
of the  heart was so great, as to occasion
death by a rupture of its parietes.  The
parts which are situated  below the point
of constriction, generally languish for want
of sufficient blood  to maintain their nutri-
tive functions;—they become  atrophied,
lose all their energy,  and sometimes fall
into a  state of gangrene, as happened in
the case of the count C, referred to above.
These   consequences  are,  nevertheless,
sometimes obviated by the collateral cir-
culation accommodating itself promptly to
the wants of the organization, and com-
pensating for the interruption of the aortal
circulation,  by transmitting an adequate
supply  of blood through  its  numberless
channels.
  We  are unfortunately in possession of
no data, upon  which a  diagnosis  of con-
striction of the  aorta can be  predicated.
All the derangements  alluded to above,
may be produced by other causes, and are
consequently  insufficient  to justify any
conclusion.  Bouillaud and Renaud have
suggested, that when  an extraordinary di-
latation of the collateral circulation is  ob-
served, attended with  preternatural pulsa-
tion, especially of the  epigastric and other
superficial arteries, constriction may  be
presumed to be the cause.  If with this
condition  of these vessels, they present a
tortuous or varicos? arrangement, such as
that which is often observed in the super-
ficial veins, when the great venous trunks
are obstructed,  there  will  be additional
reason to suspect the  existence  of some
impediment in the  course  of the  aorta.
Yet even these  symptoms are equivocal,
and can  only furnish  presumptive  evi-
dence—as they  may be induced  by other
causes.
  If the disease could be discovered, life
might be prolonged in some cases, by fre-
quent and small abstractions of blood, by
a properly regulated diet,  an avoidance of
all  sources of irritation, and the  employ-
ment of all those means which are  calcu-
lated to moderate the activity of the  cir-
culation. The treatment in short, would be
the same that is  proper in  aneurism (q. v.).
  *■ 3. Dilatation of the Aorta.  Aorta-
ektasis.  (From ojoey^, aorta, and ixtaw,
dilatation.) By this term is meant a gene-
ral  dilatation of  all the coats of the aorta,
occupying more  or less of the extent of
that vessel.   It  is distinguished  from an-
eurismal  dilatation, by the latter  being
generally, though not always, confined to
a limited extent of the aorta; by the  pre-
sence in  aneurism of a tumour  more or
less manifest, either occupying the  entire
circumference of the vessel or confined to
a portion  of its walls; and finally, by the
absence in simple dilatation,  of those la-
mina? of  coagulated blood  and fibrinous
depositions, which always form within an
aneurism, and become intimately connect-
ed with the inner surface  of the sac. (See
Aneurism.)
  Notwithstanding these obvious distin-
guishing characters, the two diseases were
for  a long time confounded under the ap-
pellation Aneurism.  Some of the earlier
writers  on that  disease  maintained, in-
deed, that it always commences by a sim-
ple dilatation of the coats of an artery;
and this opinion  was particularly espoused
by  Fernelius, Forestus,  and  Diemer-
broek,  but was opposed  by M. Severin,
Fabricius Hildanus,   and  others,  who
adopting the  views of their predecessors,
referred all cases of the disease to rupture
of the tunics of an artery.  Vesalius, how-
ever,  described a case of aneurism,  which
commenced by simple dilatation,  but  ter-
minated by  rupture;  and as a similar
condition  was observed subsequently by
others,  a  majority  of pathologists  con-
curred in admitting, that the disease might
proceed either from dilatation or  rupture.
Hence,  aneurisms were divided into  true
or false, according as  the disease had its
origin in the one  or  the other  of these
causes.   Scarpa first  called in  ques^n 
AORTA. (Dilatation.)                         165
the correctness of this distinction, and in
his excellent treatise on the subject denied
the existence of such  a disease as true
aneurism.   Subsequent observations have
fully refuted this sweeping conclusion, and
a sufficient number of unequivocal cases of
true aneurism have been noticed, to estab-
lish the propriety of the former division of
the disease into true and false. It is, never-
theless, but just to Scarpa to remark, that
he admitted the existence of a species of
dilatation of the arteries; and, in a later
work, he particularly adverted to this form
of disease,  which  he contends, we think
very properly, should be distinguished from
aneurism.   (Opuscoli  di Chirurgia.  II.
109.  Pavia, 1825, and Appendice alV Op-
era sulF Aneurisma.)  The same grounds
have been  taken  by Hodgson; and,  al-
though the  existence of true aneurism  is
now very generally  conceded, nearly  all
pathologists concur in the.propriety of not
confounding with it  that  preternatural
dilatation of all the coats  of  an artery,
which is not attended with  the formation
of a distinct sac or pouch, and in which no
lamellated  coagula  are deposited within
the dilated portion of the vessel.
   Preternatural dilatation of tiie aorta is
of very frequent  occurrence.  Its  most
common seat is that portion of the vessel
included between its origin from the left
ventricle, and the  termination of the arch.
It may, however,  occupy any part  of
either the  abdominal  or thoracic  aorta.
The form  assumed  by the dilatation, its
degree, and the extent of the  vessel  in-
volved, are infinitely variable.  In most
cases it will be either cylindroid, fusiform,
or sac-like in appearance; and, as a gene-
ral rule, a greater  extent of the vessel will
be involved when  it assumes either of the
two first forms, than when it presents the
last character.   In the sac-like dilatation
the  tunics  are often distended only in
one direction,  and preserve their  integ-
rity  so far, that no  lamellated coagula,
or other deposits,  are formed  upon their
inner surface.  Where the whole arch, or
a considerable extent of the aorta, becomes
greatly dilated, there  are  often several
points affected with this  partial lateral
dilatation, which occasion an uneven ap-
pearance  upon the surface of the vessel,
not unlike the protuberances of the outer
surface of the colon.  These sac-like pro-
minences mostly occupy the convex face
of the arch, or the anterior portion of the
artery,  and vary  considerably  in size—
some of them being scarcely larger than a
pea, while others are so prominent as to
project  considerably beyond the adjacent
por#>ii of the vessel.   They are often at-
tended with considerable thinning of the
corresponding portion of the arterial tu-
nics; and, in  many instances, fissures,
erosions, or ulcers of the inner membrane,
are observed, manifesting a tendency to
the  development  of aneurism.   When
several dilatations exist  upon  different
portions  of the aorta,  the  .intermediate
parts are sometimes but little altered in
their diameter; but, in  some instances,
the whole extent of the vessel, from the
heart to the  bifurcation of  the iliacs, is
involved in one general cylindroid dilata-
tion, either uniform or irregular.  In cases
of this kind, the length of  the  artery,
as well as its diameter, is increased; so
that while the upper margin of the arch
ascends to the level of the top of the ster-
num, or  even into the lower part of the
neck, the thoracic and  abdominal aorta
assume a flexuous arrangement similar to
what is presented by a large varicose vein,
or the convolutions of an intestine.   This
condition was observed in a case of dila-
tation of the  aorta described by Hunter.
The length of the vessel was so much in-
creased, that it formed  several  flexures
between the  summit of the  thorax  and
where it glides between the fissures of the
diaphragm.
   Sometimes the aorta is only  dilated
above the semilunar valves, where it be-
comes distended  in form of a large ovoid
sinus, capable of receiving the tips of the
whole of the fingers.  In nearly all cases
in which the dilatation exists at the origin
of any of the .vessels which proceed from
the aorta, they, in like manner, participate
in the distention.  (Hodgson. Erhardt,
de  Aneurismat.   aorta  comment,  anat.
path. p. 5.   Lips. 1820.)   This  is espe-
cially true of the coronary arteries—those
vessels which proceed from  the arch, and
the cceliac.  There are, nevertheless, some
exceptions.   Laennec has remarked, that
the left subclavian artery is seldom dilated,
even though the arch of the aorta be great-
ly distended.
   The degree to which the dilatation may
extend, without a rupture taking place, is
very  considerable,  especially when  the
disease is confined to a small extent of the
vessel, and assumes the fusiform or sac-like
arrangement.  Scarpa  reports a case in
which the sinus  of the aorta, above the
valves,  was  so dilated  that the tumour
measured eight inches in height and five
in diameter, (Opusc. di chirurg. II. 112.)
although no coagula or lamina had formed
upon  its inner surface.  A similar case has
been described by Bertin and Bouillaud,
(Traite des  malad.  de caur, &c.  104.
Paris, 1824.)  and  many, of a like charac- 
166
AORTA. (Dilatation.)
ter, have been recorded by different writers.
Even when the whole extent of the aorta
is involved in the dilatation, the size may
be enormously increased.  The case re-
ported  by  Hunter, already referred to,
furnishes  an  example of this extraordi-
nary expansion of its coats.  Bertin and
Bouillaud remark, that it is sometimes
dilated  to triple or quadruple  its natu-
ral  size, so  as  to resemble  the  colon;
(loc. cit. 121.) and Laennec observes, that
in some cases this vessel, from the heart to
the bifurcation of the iliacs, is distended to
the diameter of two fingers' breadth.  (De
FAuscult. medial. II. 689.  Paris, 1826.)
By Testa it is described as being occasion-
ally dilated, throughout the whole of this
extent to more than three times its natural
volume (Malattie deF cuor, &c. Bologn.
1810-1811.);  and a case is reported  by
Paschalis Ferraria, in which the orifice
of the aorta was extended to such a de-
gree, as to receive the arm.  (Delle morti
et malattie subitance,  apud  Burserius,
loc. cit. 225.)
  Dilatation of the aorta seldom exists to
a great extent, without  being attended
with more or less change of the texture of
its tunics, and considerable modification of
its physical properties.   The coats of the
vessel become compact and rigid, and are
in most cases much thickened.  When
the dilatation is  considerable, the artery
is divested of all its suppleness and elasti-
city, and is frequently found flattened and
collapsed after death.  Its  fibrous tunic,
which is generally thickened, is remarka-
bly fragile; and, between it and the lining
membrane, the whole walls of the vessel
are studded over with scales, or plates of
calcareous deposit, some of which  even
project through the delicate internal mem-
brane, and are in immediate contact with
the  blood.  In many cases,  where these
calcareous transformations do not exist, the
internal surface of the vessel presents an
infinity of minute specks of a  yellowish
colour, or there are numerous erosions, or
abrasions of the  internal membrane;—
sometimes small cracks, fissures, or even
ulcers; and, in some  instances, there is at
many points a species of atheromatous or
tuberculous degeneration.   The external
coat though thicker and denser than natu-
ral, is so brittle that it can be torn by the
slightest force.  In some  few instances,
indeed, the whole  of the coats become so
fragile, that they are incapable of resist-
ing  the  impulse and distending force of
the  column  of blood, and  sudden death
is induced by rupture.   The same event
may be induced by an ulcer implicating
the  coats  of the vessel;  and  it  is not
unusual for dilatation to  be. followed or
accompanied by such a condition, which,
when it takes place, if it does not termi-
nate in perforation, is apt to give rise to
aneurism.  In some instances of dilatation
of the aorta, the brittleness or fragility of
the coats adverted to, is  confined to the
serous and fibrous tunics; the cellular be-
ing highly compact and resistant, but de-
void of elasticity.
  It has been  remarked, that one impor-
tant distinction 'between simple dilatation
and aneurism is, the absence in the former
of those  lamellated fibrinous concretions,
which always exist in the sac of the latter.
To this, however, there are some apparent
exceptions.  Examples of dilatation occur
occasionally, in which the inner surface of
the vessel  is found lined by these forma-
tions, and sometimes even by proper pseudo-
membranes, indicating the previous exist-
ence of aortitis.  In the thirty-sixth case
reported by Bertin and  Bouillaud, the
aorta was lined by a cylindrical coagulum,
which prevented the blood from being ex-
travasated through the  numerous ulcers
occupying its coats.  (Op. cit.  p. 88.)  Mr.
Guthrie also refers to similar examples in
the Hunterian Museum; and very correctly
remarks, that when dilatation has proceed-
ed  to  a  great extent coagula are often
found  in the vessel;  but  they have more
the appearance of accidental, irregular for-
mations, than  of deposits in concentric
layers.  When, however, the inner  coat
has  suffered abrasion or rupture, coagula
may be deposited in layers, although not
to the same  extent as in  a small, or even
recent aneurism.  (On the Diseases and
Injuries of the Arteries.)
   It is difficult to determine satisfactorily
what particular modification of the proper-
ties of the coats of the artery is instrumen-
tal in giving rise to this pathological state,
and how far it is attributable to vital, and
how far to mechanical influences.   The
latter  certainly operate in some cases; yet
unassisted they are not adequate to  pro-
duce the effect.  Hence it has been  sup-
posed  by some, that dilatation of the aorta,
or at least the  predisposition to that state,
is owing either to a state of atony or para-
lysis of the coats of the vessel, or to the
pre-existence of chronic inflammation, by
which they are first softened and divested
of their elasticity, and afterwards dilated,
because of their inability to resist the dis-
tending force of the natural impulse of the
blood.   The former cause, we doubt not
is efficient in some cases, especially .when
associated with active hypertrophy of the
left ventricle, or any condition of the heart
calculated to occasion it  to cjmmunicate 
AORTA. (Aneurism.)
167
 a preternatural impulse to the blood, or
 when it coexists with an obstacle to the
 free transmission of that fluid. It is never-
 theless probable, that the dilatation is more
 frequently attributable to a state of chronic
 irritation, modifying the nutrition of the
 arterial tunics;  since  the traces of  this
 pathological state which are so often ob-
 served,—the alterations of colour;   the
 thickening and alteration of the textures
 of the  several coats;  the  pseudo-mem-
 branes; abrasions; ulcerations;  osseous
 transformations; the atheromatous depo-
 sits, &.c, all seem  to  point to this cause
 as the principal source of the mischief
 It has been ascertained, moreover,  that
 inflammation of the coats of an artery al-
 ways  renders them soft and fragile,  and
 destroys their elasticity; and these condi-
 tions  once  induced, the  impulse of  the
 blood  would be amply  sufficient to give
 rise to the dilatation, because the coats of
 the aorta would be no longer able to afford
 that resistance  which they do in a state
 of health.
   The symptoms which attend this  dis-
 ease of the aorta, are not sufficiently dis-
 similar to those which characterize some
 of the forms of aneurism, to enable us to
 distinguish  the two diseases.  In some
 cases, indeed, where the dilatation is not
 considerable, there being  no coagula or
 preternatural deposits  within  the  vessel
 to interrupt the stream of blood, or embar-
 rass the circulation, little or no  inconve-
 nience is experienced.  When the disease
 is more formidable, there are often violent
 pulsations in the course of the aorta, great
 embarrassment and irregularity in the ac-
 tions of the  heart,  frequent  palpitations,
 suffocation,  syncope, and the usual phe-
 nomena which indicate  disease  of  the
 heart, or aneurism of the aorta.
   The disease, we have remarked,  has
 considerable tendency to terminate in  the
 development of aneurism.   Sometimes,
 however, the coats of the  artery become
 so far divested  of their cohesiveness,  that
 rupture takes place, and the individual is
 destroyed by a sudden  extravasation of
 blood.   Dilatation may nevertheless exist
 in  a very considerable  degree,  without
 occasioning either of these consequences,
 and continue throughout a series of years,
 with very trifling disturbance of the func-
 tions.   Like diseases of the heart how-
 ever, it is very apt to occasion serous effu-
 sions, and destroy the  patient by general
dropsy.
   Preternatural dilatation  of the  aorta,
 when  it is known to exist, must be treat-
ed upon the general principles which have
 been laid down for the management of
 chronic aortitis; and when its symptoms
 are urgent the course  prescribed for the
 treatment of aneurism  will be proper.
   $ 4. Aneurism of the Aorta.   The ob-
 servations which  are  to be made under
 this head, are intended to apply to aneu-
 rism proper, in contradistinction to simple
 dilatation of the  aorta, which  has  been
 already described.   The division of the
 disease into true and false aneurism, will
 likewise be retained;   inasmuch as,  not-
 withstanding the opinion of Scarpa that
 such a form of the disease does not exist,
 a sufficient number of authenticated cases
 have been examined, to establish an oppo-
 site  conclusion.  It must be  confessed,
 however, that true aneurism is  compara-
 tively rare, and that a very large propor-
 tion of cases are of that variety, denomi-
 nated false aneurism.
  1. Anatomical Characters of Aneurism
 of the Aorta.    "
  A. True Aneurism. True aneurism, like
 simple dilatation,  may assume   either  a
 sac-like, a fusiform, or a cylindroid shape.
 The first is perhaps the most frequent:—
 the last, the rarest form of the disease.
 In the first, the dilatation generally takes
 place upon one side of  the vessel, and all
 the  coats  participate  in the distention.
 This gives rise to a tumour more or less
 considerable, upon the  corresponding por-
 tion  of the  vessel, which is generally
 rounded,  but  not  unfrequently uneven
 upon the surface.  The principal seat of
 these tumours is the ascending portion of
 the aorta and its arch, the anterior or lateral
 faces of which are most frequently affect-
 ed.  Their  size  is seldom considerable,
 owing to the  resistance of the middle
 coat; but in some instances, when seated
 upon the substernal portion of the vessel,
 they have been known to attain'a great
 magnitude,  inclining towards the right
 side of the thorax, and forcing the left lung
 upwards and  backwards.   (Bouillaud.)
 When carefully dissected,  the  walls of
 such aneurisms are found to be composed
 of all three of the coats of the aorta, the
 distended portions of which are either
 thickened or attenuated, and frequently
 present traces of chronic  inflammation,
 either characterized by alteration of co-
 lour, or some of the modifications of tex-
 ture already described.  In some instances,
 the sac communicates with the cavity of
 the vessel by a narrow neck, in which all
 the tunics can  be recognized.   This dis-
position, however, is not always observed;
the dilatation in some cases occupying the
coats of the artery to a greater extent, and 
168                          AORTA.  (Aneurism.)
allowing a freer communication between
it and the sac.  The latter contains more
or less coagulated blood,  which  is often
disposed in irregular confused masses, but
is occasionally deposited in distinct layers,
which form a concentric series.
  Although true aneurisms of this  kind
take place in the portions of  the vessel
indicated, they are not confined to these
points, but may occur in any part of either
the thoracic or abdominal aorta. N^egele
has reported a case, in which a  true aneu-
rism, which  had attained  the  enormous
weight of five pounds, occupied the latter
portion of the vessel, immediately beneath
the point at which  it emerges from be-
tween  the pillars of the  diaphragm.  It
was found on dissection, that all three of
the aortal tunics entered into  the forma-
tion of the sac, which was filled by a mass
of fibrinous concretions of a firm consist-
ence, and of a whitish red colour, inclined
to yellow. (D. Fr. Nege^e. Epist. qua hist.
aneurismat. in aort. abd. continent.  Hei-
delburg, 1816.)  Jules Cloquet has  like-
wise reported a case of true aneurism of
the abdominal aorta, which was  situated
immediately  above its bifurcation.  The
cavity  was filled with  superincumbent
layers of fibrinous concretions, in the cen-
tre of which was found an artificial canal,
through which the blood passed.  (Surgi-
cal pathology, &c., translated by Garlick
& Copperthwaite. p. 114. pi. 3. Lond.
1832.)  In some cases, indeed, different
portions of the aorta are simultaneously
the seat of aneurism; and instances oc-
casionally occur, in which the whole arte-
rial system is affected in this way.  The
author just cited, has published a case of
this kind.  The  tumours varied  in  size,
from a hemp-seed to a large pea.  Some
of them were found upon the aorta and its
principal  divisions;  but  these  were  less
prominent and   fewer  in  number,  than
those upon the arteries of the extremities,
which were so closely clustered together,
that they formed strings of knots;  and
even those of the  lower extremities, which
were the least  numerous,  amounted to
several  hundreds  in number.   In none
of these  tumours was any rupture of the
internal or middle coat observed; nor in
any of the arteries, was there ossification,
or  steatomatous  degenerescence.  (Op.
Cit. p. 105. pi. 2.)   Pelletan also  met
with a case, in  which sixty-three aneu-
risms, from the size of a  filbert to that
of an egg, occupied the arterial system
of an individual.  (Clinique Chirurgicale.
II.  1.)
  The fusiform variety of true aneurism,
is intermediate between the sac-like, and
the cylindroid:—it represents the transi-
tion from the one to the other.   Like the
preceding variety, its most frequent seat
is the ascending portion of the aorta and
its arch.  It is generally characterized by
a uniform dilatation of the coats of the
vessel  in every direction,  which, at the
same time, present the usual evidences of
chronic inflammation that are observed in
the other forms of the disease.   They are
friable in their texture, and of an unequal
thickness, — being attenuated  at  some
points, and  at others considerably thick-
ened.  Sometimes, moreover, the lining
membrane is rough upon the  surface, and
presents numerous fissures, while between
it  and the  fibrous coat there are often
plates  of calcareous deposit.   These tu-
mours, though often  small, in  some in-
stances attain a great  size.   Breschlt
has reported  two interesting cases.   In
one, the tumour which occupied the tho-
racic aorta, on a level with the eighth and
ninth  dorsal  vertebrae, measured  three
inches in  diameter  and four  inches  in
length :  in  the other, which  extended
from the sigmoid valves to the origin  of
the innominata, the  diameter of the tu-
mour was five inches. (Memoires Chirur-
gicaux sur  differentes  especes  d'aneu-
rismes. p. 15-23.  4to. Paris.  1834.)  In
both these cases, the tumour was occupied
by coagulated blood, and in one of them,
by lamellated fibrinous concretions. Other
cases of the same kind might be cited;
and in the work just referred to, pi. iv., a
very interesting one, which was observed
by Amussat, is figured.
  The cylindroid variety of true aneurism
of the aorta  is  exceedingly  rare.  We
know  of no well authenticated case  in
which  there was not rupture of the inter-
nal coat of the  artery.   The nearest ap-
proximation to this condition, of which we
have any knowledge, is the case reported
by Hunter, to which  reference  has been
made already, under the head of dilatation.
It  may be remarked, however, that aneu-
rism often  takes on a mixed character;
viz.—consisting at first of  a dilatation of
all the coats of the aorta, the two internal
tunics  finally give way, and the external
becomes  dilated, to  form the  sac.  We
shall have  occasion, therefore, under the
next head, to speak of examples of cylin-
droid aneurism of this great vessel,  with
dissection of the internal tunic, and  shall
merely observe at present, that although
true aneurism of the aorta, and other large 
AORTA. (Aneurism.)
169
vessels, seldom  assumes  the  cylindroid
form, it is not uncommon in arteries of
smaller calibre.
  B.  False Aneurism.  This  variety of
aneurism, the distinctive  characters of
which are a destruction of the  internal
and  middle coats of the artery, with a
dilatation  of the external,  occurs  much
oftener than the preceding.   Like that
form of the disease, its most common seat
is the ascending aorta, or the arch, espe-
cially that portion of it which gives off
the innominata.   No part of the vessel,
however, is exempt,—cases frequently oc-
curring either in its thoracic or abdominal
portions.  The part  immediately beyond
the termination  of the  arch, that in  the
vicinity of the pillars of the diaphragm
above and below, and the origin of  the
celiac  artery, and  finally the  vicinity
of the bifurcation, seem to be most  lia-
ble  to the disease.   In some cases, seve-
ral  aneurisms exist  in  different  portions
of the  vessel,—one or more of  these
being large,  while  the others are  com-
paratively small.  The shape of the tu-
mour, as in true  aneurism,  may be either
sac-like, fusiform or cylindroid, though the
first is by far the most common, because
of the tumour being generally developed
upon one side of the artery.   The last is
very rarely observed.   The volume of the
tumour varies, according to the degree of
resistance  afforded by the  surrounding
parts,—sometimes attaining  the  size  of
the head of a full-grown child, when they
are yielding, but when they are resistant,
being much smaller.  It should be remark-
ed, however, that when an aneurism takes
place upon that portion of the aorta which
is  included  within  the pericardium,  the
tumour seldom  attains a large size,  be-
cause the  cellular coat of that part of the
vessel being exceeding feeble, the tumour
is generally  ruptured, before  its volume
can become considerable.
  The manner in which a false aneurism
of the aorta has  its origin varies in differ-
ent cases.  In a majority of instances, the
development of the tumour is preceded by
a solution of continuity of the internal  and
fibrous coats of the vessel, produced either
by ulceration, atheromatous degeneration,
or calcareous deposits, formed between
them, and projecting through the former
into the cavity of the artery.  Under these
circumstances, the cellular coat has to sus-
tain the whole force of the lateral disten-
tion of the blood, and as it yields readily
to this influence, it becomes distended, the
blood insinuates itself between it and the
fibrous coat around the solution of contin-
  VOL. 11.          15
uity, and in the end,  a sac  or pouch of
variable  magnitude  is  formed, which is
filled with blood, and communicates with
the cavity of the aorta.   Such tumours
are at first confined to one  side of the
aorta, generally to its anterior, superior,
or inferior faces; but as they augmeat in
size, a greater extent of the circumference
becomes implicated, and in some cases
the tumour surrounds the whole contour.
But while false  aneurism generally has
its origin in this way, there are cases in
which  its  development  is preceded  by
changes  which  are  slightly different.
Thus, the simple  dilatation of the aorta
occasionally gives rise to fissures of the
lining membrane, which  are probably not
so much owing to the mere mechanical
influence of distension, as to a diminution
of the cohesiveness of the tissue, induced
by disease.   These  fissures  are  mostly
transverse, but  occasionally  longitudinal
or oblique;—the blood insinuates  itself'
beneath the edges of the membrane, and
by gradually detaching it from the tunics
which  are exterior to it, sometimes dis-
sects the coats of the artery for some dis-
tance.  In some cases, the fissures extend
in like manner through  the fibrous  coat,
and the cellular undergoes the same modi-
fications, as when the disease has its ori-
gin in the manner described above.  The
cause of this accident is a preternatural
friability of tissue,  excited  by previous
disease, which  renders the arterial coats
incompetent to  resist the force of the  la-
teral distention  of the column of blood;
and if it exist simultaneously in the cellu-
lar coat complete rupture, instead of aneu-
rism, will sometimes ensue.  An approxi-
mation  to this  condition was found  by
Nicholls, in the  body of George II.  A
fissure,  ranging in  a  transverse direc-
tion to the extent of an  inch and a quar-
ter, was found occupying the aorta, and a
small quantity  of blood  extravasated be-
neath  the cellular  coat  of the  vessel.
Rupture probably would have taken place
in a short time, had it not been that death
occurred too early to allow the necessary
changes to ensue.
   The best example of dissection of the
coats of the aorta by aneurism, is one re-
ported by Laennec. (Auscultation mediate.
II. 700.)  The arch of the aorta was di-
lated to  such an extent, as to be capable
of containing an apple of medium  size.
The descending portion of the vessel, two
inches below the termination of the  arch,
presented upon its inner surface, a trans-
verse fissure, which occupied two-thirds
of its circumference, and extended through 
170
AORTA.  (Aneurism.)
the internal and fibrous coats.  The edges
of this division were thin, uneven, and of
a lacerated appearance  at  some  points.
The cellular  coat was  healthy,  but de-
tached from the fibrous, from the fissure
in question, to the origin of the iliacs; so
that at first view, the cavity of the aorta
seemed to  be  divided into two, by an in-
termediate  partition.  The detachment oc-
cupied about two-thirds  or half the cir-
cumference of the vessel, and was princi-
pally  confined to its posterior  portion,
though  it  occasionally wound around  it.
In  the  coeliac and  primitive  iliac arte-
ries, upon which it extended for some dis-
tance, it was complete.
  Two similar cases are mentioned by
Guthrie (Loc. Cit. 40. 43.); but in them,
the dissection or detachment of the cellu-
lar from the fibrous coat was less exten-
sive.  In one  of them, the separated cel-
lular tunic formed a long pouch  on the
anterior  part  of the descending aorta,
about six inches in  length,  extending to
the sides,  and in  one place nearly sur-
rounding it  A horizontal fissure, about
half an inch  in extent,  near  the upper
part of the swelling, allowed the blood to
pass through the inner and middle coats,
and to effect this separation, which could
only have arisen from disease previously
existing in the part.  The other case was
that of an  old woman who died suddenly.
The ascending portion of the aorta was
greatly dilated, and  of a red wine-lee
colour.  Just below where the innominata
is given off, the inner and  middle coats
were ruptured, for half the  circle of the
vessel, on the great curvature, as clean as
if cut with a knife, and in a straight line
around.  The  effused blood separated the
outer from the fibrous coat, down to its
origin, along the fore part and  around the
great curvature, to the back part,  dissect-
ing thereby two-thirds of the artery.  The
dissecting  process was also  extended for
an  inch beyond the left subclavian, along
the descending aorta. For additional cases
of the  same kind, see Aneurism, Vol. I.
p. 498.
  Under the  head  constriction  and  ob-
struction of the aorta, reference was made
to a species of lesion of that vessel, which
was supposed  by Corvisart to constitute
a cause  of aneurism.  The condition  to
which  we  allude was a  kind of fibrinous
cyst developed upon the course  of the
vessel,  of  about two lines in thickness,
which  contained a  substance somewhat
softer than suet of a deep red colour, and
analogous  in  appearance to the  ancient
coagula which adhere to the inner surface
of an aneurismal sac.  Corresponding to
the site of the tumour, the external tunic
of the aorta  was destroyed,  and the re-
maining portion of the wall of the vessel
was greatly attenuated. (Essay on the or-
ganic diseases of the Heart, &c.  Ameri-
can edit p. 241.  Philad. 1812.)  He ob-
served two cases of this kind, and others
have been  noticed subsequently, by seve-
ral pathologists.   Hodgson, however, has
argued to prove that these tumours should
not be considered as a cause of aneurism,
but the remains of that disease, where a
cure has taken place spontaneously. This
view  has  been adopted  by  Bouillaud
and  a majority of  the  pathologists of
the present period, and is probably much
more  correct than that advanced by Cor-
visart.
  C.  Mixed  Aneurism.   This term  has
been variously applied by different writers.
We shall employ it to express a form of
aneurism, which consists of a destruction'
of the two external  coats of an artery,
and  a protrusion  of the internal  tunic
through the opening,  after the manner of
a hernial sac. Haller first demonstrated,
by experiments made on the mesentery
of frogs and other animals, the possibility
of such a disease, and similar conclusions
were  adopted by William Hunter.  The
disease  has been  denominated  internal
mixed aneurism, and it is said that Du-
puytren and Dubois some  years  since
presented examples of this form of disease
to the Faculty of Medicine of Paris. Many
pathologists,  however, still  question  the
existence of such a form of aneurism, and
it must be acknowledged that such an oc-
currence is exceedingly rare.   It is pos-
sible,  nevertheless, when the fibrous and
cellular coats of an  artery have been de-
stroyed by previous disease, for the serous
coat to become sufficiently fortified by an
adventitious deposit  of lymph upon its
outer  surface, to become distended, or pro-
truded, in the manner represented, with-
out being  immediately ruptured by  the
lateral impulse of the column of blood.
Without this preliminary change, we con-
ceive such an event would be impossible;
but with it an aneurism of the kind in
question might possibly be  developed in
the aorta, or  some of the larger arteries.
Trousseau and Leblanc have, indeed, re-
ported a case, in which an aneurismal tu-
mour of this  kind was found in the aorta
of ahorse (Archiv. Generates. XVI. 189.),
and Lauth reports an instance, in which
three such tumours occupied the aorta of
one subject  (Lobstein.  Traiti d'Anat.
Path. II. 583.)  Dupuytren  also disco- 
AORTA.  (Aneurism.)
171
vered two aneurisms of the popliteal ar-
tery, situated an inch apart,—one as large
as a pigeon's egg, the other of the size of
an almond, in which it was found that the
internal and external tunics were dilated,
while the fibres of the middle coat were
forced asunder, to allow  the inner tunic
to protrude through it (Archiv. Generates.
XXIV. 143.)
  The  condition  of the  sac,  and  the
changes which take place within it, have
been  so  fully  described  under the head
Aneurism, that we shall merely refer to
that article, for information on these topics.
(See  Aneurism, Vol. I. p. 497, et seq.)
   2.  Of the influence exercised by Aneu-
rism of the Aorta upon the adjacent parts.
Aneurisms  of the aorta,  whatever their
situation, necessarily encroach  more or
less upon the surrounding parts, according
to their size;  and when the organs which
are in contact with  the  tumour  are so
firmly fixed that they cannot yield, serious
embarrassment of function  will  be  pro-
duced.   Hence, aneurisms  affecting the
ascending  aorta, and the arch, occasion
more disturbance than those which attack
the abdominal portion of  the vessel.  The
organs  in  the latter cavity, indeed, yield
so readily, that the simple pressure of an
aneurismal tumour,  except when its vo-
lume is very  enormous, seldom  occasions
much inconvenience, although it may give
rise to formidable consequences  in a dif-
ferent way.  The thoracic organs, on the
contrary, being surrounded by bony walls,
suffer much  from such pressure.   Thus,
an aneurismal tumour of the arch,  may
 encroach so much upon the trachea and
bronchia, as to embarrass respiration: it
may  impede  deglutition  by encroaching
upon the oesophagus; force the heart and
lungs out of their natural situation, and
interrupt their functions; obstruct or ob-
literate the vena cava, vena azygos, and
other great veins in the upper portion of
the thorax; compress the important nerves;
obstruct the thoracic duct—in short, dis-
place nearly all the important organs, of
the thorax, destroy  their relations,  alter
their texture,  and finally deform or break
up the walls  of the  cavity itself.
   Instances of compression of the trachea
from aneurism of the arch, are of common
occurrence.  Within a few days we have
dissected an interesting case of this kind,
which occurred in an  individual who had
been for a long time suffering from symp-
toms of asthma.   An  aneurismal tumour
of small size,  occupied the posterior face
of the vessel, where it passes in  front of
the trachea, and the cellular coat adhered
so intimately to the anterior part of the
trachea, that the latter, which was a little
indented upon its inner surface, closed up
the aneurism, and prevented it from rup-
turing.  The pressure was still further in-
creased,  by a considerable glandular tu-
mour, which was wedged in between the
anterior surface of the arch, and the cor-
responding portion of the sternum. When
the pressure upon the trachea is consider-
able, the respiration is generally laborious
or wheezing,  and the case is apt  to be
mistaken for asthma.  In some cases, when
an aneurism of great size exists near the
origin of the aorta, the tumour encroaches
upon, and displaces the heart.   Neumann
has reported a very interesting example
of this kind, in which the tumour covered
the whole extent of the right ventricle of
the heart and even extended beyond its
limits, downward and on the right  while
on the left,  it reached the line of the in-
terventricular septum, and forced the heart
backward  towards  the  spine.  (Journal
Complimentaire.  V.  87.   Paris, 1819.)
Laennec saw a case in which the tumour
obstructed  the  thoracic duct  and   occa-
sioned engorgement of all the lacteal ves-
sels.   Corvisart and  Bouillaud  found
the  superior  vena  cava so much  com-
pressed  by an aneurismal tumour,   as to
occasion frequent attacks of cerebral con-
gestion  and apoplectic symptoms.  (Diet.
de Med. et  de Chir. Prat. II. 403.)   Bee-
 vor related  a case to  the Westminster
 Medical Society, in which the vena cava,
 about  an inch above the auricle, was im-
 pervious to the extent .of half an  inch,
 and communicated by a rent, higher up,
 with the  cavity of the enlarged  aorta.
 (Lancet. II.  63.  1832-33.)  In another
 case, observed by Reynaud, the superior
 cava was nearly obliterated by an  aneu-
 rism of the ascending aorta.  Besides be-
 ing flattened by the tumour, it was  occu-
 pied by a fibrinous concretion,  which
 allowed merely a small stream of blood to
 reach the auricle. (Journ. Hebdomad. II.
 109.)  Sometimes the common carotid ar-
 tery is obliterated (Sir A. Cooper.   Med.
 Chir.  Transact. I.  12.), and the subcla-
 vian may  experience a similar change.
 (Hodgson.  Loc. Cit.)   Serious inconve-
 nience  may likewise arise from the pres-
 sure of the tumour upon the pneumogas-
 tric or  recurrent nerves,   Huguier and
 Cruveilhier have reported cases, in which
 aphonia was induced by the compression
 of the recurrent nerves.  In the instance
reported by the first individual, there was
also great difficulty of breathing, in con-
sequence of the encroachment of the an- 
172                         AORTA.  (Aneurtsm.)
eurismal tumour  upon the left bronchus.
(Archiv. Gen. Feb. 1834.)  Pressure upon
these nerves and the phrenic, may like-
wise  occasion much  pain and suffering.
(Paillard.  Journ. Hebd. No. 45.  Diet.
de Med. HI. 308.)
  When  the tumour attains  a  greater
volume, it not unfrequently protrudes from
the cavity of the thorax in the direction
in which it encounters  the least resist-
ance,—sometimes, however, even  destroy-
ing the bones in  its progress.  When it
occupies the arch, it is apt to ascend from
beneath the sternum  into the lower part
of the neck, in which situation it may be
mistaken for an aneurism of the  innomi-
nata.  It also protrudes, in some instances,
upwards and laterally, behind the clavicle,
and in such cases great care is requisite
not to confound it with an aneurism of the
subclavian artery.  Occasionally it destroys
the sternum,  and protrudes through it;
occasions absorption of one or more of the
ribs;  gives rise to curvature, luxation, or
distortion of the clavicle (Guatfani, apud
Lauth. p. 168.),  and even inflicts its ra-
vages  upon the  scapula.  (Duverney.)
When the descending portion of the aorta
is the seat  of the tumour,  the bodies of
the vertebrae are frequently destroyed to a
considerable extent, and if the  tumour be
large, destruction of the adjacent portion
of the ribs often takes place either by ab-
sorption or caries. In large aneurisms of
the abdominal aorta,  the kidneys and in-
testines are  frequently forced out  of their
natural position,  and the tumour may de-
scend into the cavity of the pelvis, or even
reach below Poupart's ligament,  as hap-
pened in a case reported by Elliotson.
  All these  effects are sufficiently formi-
dable, and many  of them are not unfre-
quently fatal, in  consequence  of the  se-
rious  disturbance of function with which
they are associated.  Yet in proportion as
the disease  makes progress, others of .a
more  alarming nature ensue.  As the  vo-
lume  of the tumour increases, important
alterations take place in  its walls.  Ad-
hesive inflammation is developed in  the
structures which  compose them,  as well
as in the surrounding  parts: adventitious
attachments form  between the sac  and  the
parts with which  it is in contact and  the
parietes becoming attenuated, or softened,
by disease, or destroyed by ulceration or
interstitial absorption, the aneurism either
bursts  into some  of* the natural cavities,
or the  hollow organs, or it  makes  its
way externally, and its  contents finally
find an  exit through  the  skin.   Such
an event  is almost always immediately
fatal, yet in some instances death has not
ensued  for some time subsequent to the
accident—the  fatal  termination  having
been averted, by the aperture being closed
up by a coagulum.
   It has been already remarked, that when
an aneurism occupies that portion of the
aorta which is  contained within the peri-
cardium,  rupture takes place readily, on
account of the great thinness of the  cel-
lular coat of that portion  of the  artery.
Aneurisms, therefore, often  rupture into
the cavity of this membrane, and the heart
is found after death completely embedded
in a  mass of coagulated blood.  We  have
observed two or three cases  of this kind,
and  examples are so numerous, that we
need not  refer to particular ones.   Next
in point of frequency, is the rupture of the
aneurism  into  the  cavity of the pleura,
especially the left, extravasation into the
right being comparatively rare.  Rupture
into  the cavity of  the abdomen is  like-
wise  common;  and  in  some  instances,
when the  descending aorta is affected, the
tumour bursts into the posterior mediasti-
num (Wolff.  Nov. Act. P'etrop. V. 1786.
Hodgson. Op. Cit.), or into  the anterior
mediastinum, as happened in a case re-
ported by  Reguier  to the Anatomical So-
ciety of Paris.  (Rev. Med.  I. 315.  1834.)
   Less  frequently,  the  tumour forms a
communication with some  of the  hollow
organs.  Of these openings, those into the
trachea and oesophagus are the most com-
mon.  Cases of communication with the
trachea have been reported by Heurnius
(in Lieutaud. Hist. Anat. Med. II.  Obs.
802.), Corvisart (Loc. Cit. 256.), Boyer,
Richer and (Mem. de la Soc. d'Emulat.
IV. annee.), Bouillaud (Traiti des mala-
dies de Cceur, &c. 107.), Lambert (Journ.
des Progres. III. 1830., and Amer. Journ.
of Med. 8c. VII. 229.), Wright (Amer.
Journ. of Med. Sc.  IV.  345.), Regmer
(Revue  Med.   I.  315.   1834.), Corbin
(Journ.  Hebd. III.), Montault (Lancette
Francaise. No. 9. Sept. 1834.), and others,
whose observations are not at hand.
   The walls of the  oesophagus being thin
and destitute of the cartilaginous struc-
ture which forms so considerable a portion
of the trachea, cannot resist so effectually
the progress of the ulcerative inflamma-
tion which takes place in the sac. Hence
aneurisms of  the thoracic  aorta,  which
contract adhesions  with  this tube, often
terminate  by forming an  opening into its
cavity. The records of the science furnish
numerous  cases of this kind, but as only a
few of them have been indicated  in  the
ordinary systematic works,  the following 
AORTA.  (Aneurism.)
173
references  to  the   principal  examples
which  have been reported, may serve to
facilitate the further investigation of the
subject.  (Matanus de Aneuris. pracord.
morb. VI. 120.   Sauvaoes. Nos. method.
II. 388.  Amst. 1768.  Eph.  de Montpel.
VI. 219.   Philosoph. Transact, abridged.
II. 420.  Dupuytren, in Corvisart Op.
Cit. 256.  Bulletin de la Soc. d'Emulal.
1812.  p. 14.  Ouvrard.  These No. 53.
p. 25. Paris, 1811.  Bulletin de la Facul-
te.  1812.   Bulletin des Sciences Med. II.
411. 1808.  Bibliotheque Med.  LIU. 68.
LIV. 343.   Lond. Med. and  Phys. Jour.
LIII. 96.   Fanconneau-Dufresne, These
No. 220. p. 25.  Paris, 1824.   Recueil de
Med Militaire.   XXII.  329.   Erhardt,
Loc. Cit. 22.  Joseph Frank.  Prax. Med.
Vol. II. part 2. p. 336.  Medico-Chirurg.
Transact.  II. 244.   Bertin  and Bouil-
laud, Op. Cit. Obs. XL p. 110.  Laennec.
Auscult. Mediat. II. 204.  Rust's Maga-
zin. XXII. 447.  Huguier.  Arch. Gen.
Fev. 1834.   Porter. Dublin Journ. Med.
and Chem.  Sc.  IV.  209.   Wright.
Americ.  Journ.  Med.   Sc.   IV.  345.
Samuel  Cooper.    Medico-Chirurgical
Transact.   XVI.)   In  this  latter  case,
the aneurismal tumour pointed under the
left scapula, but afterwards burst into the
oesophagus, and several  pounds of blood
were passed by vomiting and stool.  The
individual  nevertheless   survived nearly
two months, in the  pursuit of an active
employment,  the  rupture being, during
that period,  plugged up by a fibrinous
concretion.  Such cases are nevertheless
almost always immediately  fatal, blood
being discharged copiously by vomiting,
and the  stomach is  found distended with
it after death.
  Aneurismal tumours affecting the as-
cending  portion of the aorta, or the con-
cavity  of the arch,  occasionally contract
intimate  adhesions either with the trunk
of the pulmonary artery, or one of its prin-
cipal branches. Under such circumstances,
the intermediate walls may be destroyed
by absorption or ulcerative inflammation,
and establish a direct communication be-
tween the two vessels. Such an accident
would be apt to occasion symptoms analo-
gous to those which arise from the admix-
ture of venous and arterial blood, where
the foramen ovale  or ductus  arteriosus
remain pervious.  The only cases of this
kind of which we have  any  knowledge,
are those reported by Wells, Transact.
of a Societ. for the  improvement of Med.
and Chir.  Knowledge.  III.  85.   Sue,
Journ. de Mid.  XXIV. 124.   Payen and
Zeink, Bulletin de la Facult. de Mid. No.
                 15*
3.  1819., and Nannoni, Trattato di Chi-
rurgia. II. Obs. 74.
  Compression and obliteration of the vena
cava have been already mentioned, as oc-
casional consequences of aneurism of the
ascending aorta.  In some rare instances,
extensive adhesions form between the sac
and this vessel, and a communication may
finally take place between the artery and
the vein.  In such cases, should death not
immediately ensue, more  or  less admix-
ture  of the venous  and arterial  blood  is
apt to occur, and even a varicose condition
of the vena cava may be developed,  in
consequence of its walls being distended
by the impulse of the arterial blood.  In
the case observed by Beevor,  to  which
reference has  already been made, there
was a rent of the coats of the vena cava
immediately above the impervious point,
which led directly  into the aorta.   The
azygos on the one  side, and the left sub-
clavian, and a  large pericardiac vein on
the other, emptied themselves just above
the obstruction;  but they were so dilated,
especially the azygos and the pericardiac,
that no doubt arose as to their having been
the principal channels, through which the
blood of the upper half of the body found
its exit into the right auricle. At the en-
trance of the  left subclavian, there was
another,  and a larger rent, leading also
into  the  aorta, thus constituting a second
communication  between the arterial and
venous system.   (Lancet.  II. 63.   1633.)
In the same work,  an analogous case  is
reported, which occurred at St. Bartho-
lomew's  hospital.  The countenance had
been cedematous and purple, and the small
superficial veins of the chest turgid and
almost varicose.   The superior vena cava
contained a coagulum of blood; and about
two  inches  above its  entrance into the
auricle, there was found a  round opening,
communicating with the aneurismal sac.
(Op. Cit. p. 667.) A very interesting case
has likewise been reported by  Syme,  in
which a  large aneurismal tumour, which
occupied the abdominal aorta in the vici-
nity of its bifurcation, adhered to the cor-
responding portion of the vena cava, and
communicated  with that  vessel, by an
opening of the size of a six-pence.  The
individual was affected with violent pulsa-
tions in the part, coldness of the lower ex-
tremities, and  oedema.  (Edinb. Medical
and  Surg.  Journ.  and Revue Mid.  I.
456.  1833.)
  A communication may also be establish-
ed between the arterial and venous circu-
lation, in cases of aneurism of the aorta,
by the tumour bursting into the right auri- 
174
AORTn..  {*i.m;iit iam.)
cle of the heart.   Such  a teimination,
however, must be  exceedingly rare, and
the only example that has been reported,
so far as we  recollect is  one which was
observed by Beauchene.   (Bulletin de la
Facult. de Med. No. 3.  1810.   Diet, de
Mid.  Nouv. ed. III. 409.)
  The surface of the aneurismal sac some-
times becomes closely adherent with the
corresponding portion of one of the lungs,
and by encroaching upon it, occasions con-
siderable atrophy of its substance, or under
the progressive  ravages of ulcerative ab-
sorption, the contents of  the tumour find
their way into the bronchial ramifications,
and give rise to a fatal hemoptysis.  Such
a rupture may take place either into the
right  or  left lung, but it is more liable to
occur in  the latter, because of its closer
proximity  with the  descending  aorta.
Marchettis  met with a singular case of
this kind.  The right lung was so far de-
stroyed that its place was  represented by
a membranous sac merely, formed chief-
ly by a large aneurismal tumour which
had protruded  into  the lung. (Obs. 48. p.
94.)  Other examples of the termination
of aneurism of the aorta,  by the tumour
bursting into the lung, have been reported
by Palletta, Exercit. Path. II. 215. Me-
diolani,  1820.  Laennec,  Op.  Cit. 427.
Bouillaud, Diet, de Mid. et de Chirurg.
Prat. IL 405.   Melhuish, Lancet, 1.222.
1831. Nelaton, Revue Mid. in. 58.1833.
  The ravages  inflicted  by the tumour
on  the vertebrae, ribs,  sternum,  and cla-
vicle, have been already mentioned.  The
sternum especially is in some cases com-
pletely perforated, and the  integuments,
which are at first protruded before the tu-
mour, finally give way, and the individual
is destroyed by a  sudden gush of blood.
The same thing happens  when the aneu-
rism protrudes upward into the neck, or
anteriorly and laterally, between the ribs.
The bodies of the vertebra are sometimes
so far destroyed, as to lay open the spinal
canal; and a case is reported by Meriadec
Laennec, in which an aneurismal tumour
of the aorta,  terminated by bursting into
this cavity. (Revue Mid. July, 1825.) The
subject of the case was affected with para-
plegia, during the last six hours of his life.
An example of a similar kind was observ-
ed by Saloman.  (Petersb. Abhundl. 1825.
p. 164)
  Aneurism of the abdominal aorta, when
its  coats  become  too  feeble  to  sustain
the force of  the  circulation,  generally
burets into the cavity of the peritoneum.
Sometimes, however,  the blood is ex-
travasated  behind  that membrane;  and
occasionally,  the tumour protrudes out-
wards, between the lower  ribs and  the
crista of the  ilium, and if the  individual
should survive long enough, it may finally
destroy the integuments, and burst exter-
nally.  The sac, in this situation, is not
so apt to open into the hollow  organs, as
in the  thorax, yet such a termination has
been observed in a few instances.   Nan-
noni reports  one, in which  the tumour
opened  into  the stomach.  (Trattato di
Chirurgia. II. Obs. 87.)  Comstock  has
published a case, in which the aneurism
burst' into the sigmoid flexure of the colon,
(Philad.  Journal of Med. and  Phys.  Sc.
XIII. 319.), and  we think an instance is
mentioned by Sir A. Cooper, where  the
tumour formed a communication with the
jejunum. Joseph Frank, moreover, speaks
of a rupture into the duodenum, (Op. Cit.
339.) and a case  is recorded by Morgagni,
in which an abdominal aneurism  burst
into the cavity of the thorax.
   In a large majority of cases, rupture of
an aneurism of the aorta is speedily follow-
ed by death.  This event generally ensues
most promptly,  when  the  tumour opens
into one of the natural cavities, or a hollow
organ,  and especially when it takes place
through the skin. When the rupture takes
place into the pericardium, or the pleura,
independently of the effects of the sudden
loss of blood, the heart and lungs may be
overpowered  by the sudden extravasation
of that fluid upon their surface. Suffocation,
moreover, may be induced by the bursting
of an aneurism  into the trachea, bronchi,
or lungs.  But when the  sac gives way,
and extravasates the blood into the adja-
cent cellular tissue, the  result is not gene-
rally so formidable.  The aneurism only
becomes diffused, after having been before
circumscribed, and some time may elapse
before a fatal  termination takes place, by
the yielding of the parts into which  the
blood is extravasated.   Even when the sac
forms a communication with a hollow or-
gan, if the rent be small or oblique in its
course, the case does not always  terminate
fatally at the time;  but life  may be pro-
longed, for a considerable period, by the
aperture  becoming closed by a coagulum.
This event is often favoured by the occur-
rence of  syncope at the time the rupture
of the  aneurism takes  place, during the
continuance of which a firm coagulum may
form, and completely close up the breach
made in the wall of the sac.   It may hap-
pen, moreover, when the tumour is very
large,  and is occupied  by considerable
masses of coagula of a concentric lamel-
lated arrangement that the rent may range 
AORTA. (Aneurism—Causes.)                      175
in an oblique or tortuous direction through
them, and render it more difficult for the
blood to escape, while the  formation of a
coagulum will be  greatly facilitated.   In
the  case  referred to  above,  which  was
reported by S. Cooper, the individual  sur-
vived nearly two months after the aneu-
rism established a communication with the
oesophagus; a plug having formed in the
solution of continuity, by which the blood
was prevented from escaping into the gul-
let.  Instances of a similar kind have been
observed  by others, where life was  pro-
tracted for a shorter period by an analagous
condition of the parts.
   The fatal issue  of aortal aneurism does
not always depend upon a rupture of the
sac.  It may be occasioned by the influence
of the  tumour upon other organs, either
adjacent or remote;  and the effects upon
which the fatal consequences depend, may
arise either from a simple functional  em-
barrassment, resulting from the  pressure
of the  diseased  mass, or from extensive
changes of texture, excited by its presence.
The mdividual may be destroyed by suf-
focation, from obstructed  breathing;  by
inanition, from closure of the thoracic duct;
by.serous effusions into  the cavities, apo-
plexy, paralysis, or a  gradual  impairment
of the powers of life, taking place in con-
sequence of the imperfect exercise of the
functions.
   D. Causes. The causes which  give rise
to aneurism have been so fully considered
in the article which treats of that subject
that it will  be  unnecessary  to  describe
them particularly in  this place.   Still it
will be proper to notice those which tend
more particularly to give rise to aneurism
of the  aorta,  since  this vessel,  from its
great  magnitude, and its  close  relations
with the heart, is  liable to be acted on by
influences from which other arteries  are,
to a certain extent exempt
  • Sex and age may be enumerated among
the predisposing causes of the disease.   It
has been found that males are much more
liable to aneurism  than females; a liability
which is clearly referable, in part at least,
to the active physical exertion required in
their laborious avocations and  ordinary
habits.  Hodgson remarks,  that out of
sixty-three cases of aneurism observed by
him, fifty-six were in males, and only seven
in females.   This disproportion, however,
is probably greater than will be  found  to
exist generally; and it is stated by Joseph
Frank, that of the cases of aneurism which
had  fallen under his observation, about
one-fourth were in females. (Prax. Med.
Univ. Precept. II. part 2. p. 340.)  The
disease seldom takes place during the early
periods of life, nor does it very often occur
in advanced age; and when it is observed
in old persons, it will generally be found
to have been of long standing.  (Frank.
loc. cit.)  It is most apt to occur between
the ages of thirty and fifty, and manifests
a predilection for individuals of a full and
plethoric habit, especially when there  is
appended to this a gouty diathesis.  There
are likewise many occupations which pre-
dispose  to aneurism of the aorta; and this
is especially true of those which require a
constant stooping position  of the body, or
violent corporeal exertion.  Joseph Frank
remarks, that he had observed  nine cases
of aneurism in laundresses, which he im-
putes to the nature of their employment.
Scrofula, syphilis, rheumatism, protracted
attacks  of malignant fever, the imprudent
use of mercury, habitual intemperance—in
short whatever has a tendency to give rise
to a diseased condition of the coats of the
artery, may act as predisposing causes of
aneurism.  Active hypertrophy of the left
ventricle of the heart or  any cause giving
rise to continuous or often repeated accele-
ration of the aortal circulation, may, after
some time, occasion such  changes of the
structure of the vessel, as  to create a lia-
bility to the disease.  It should, neverthe-
less, be remarked, that before these causes
can give rise to aneurism, they must affect
some change of texture in the coats of the
artery, rendering them less resistant, and
disposed to become distended or ruptured,
under the influence of the  lateral impulse
of the blood.   While the structures main-
tain their integrity, the physical influences
to which they are exposed are  inadequate
to give  rise to aneurism;  and it is only
after their natural elasticity and cohesive-
ness have been impaired or destroyed by
previous disease, that such an  event can
ensue.  Whatever the remote predisposing
cause may be, the immediate predisposition
is a softening,  friability,  degenerescence,
or ulceration of the coats of the artery,
either resulting from aortal inflammation,
or at least from some modification of nu-
trition,  affecting the coats of the aorta, by
which they are rendered too feeble to sus-
tain the  onus  of the circulation.  The
manner in which these causes operate in
producing  aneurism, has been explained in
the article Aneurism, already referred to,
and under the section  which  treats of
chronic aortitis, and need not now be con-
sidered.
   The  exciting causes  are whatever  is
calculated to accelerate the circulation, or
throw a sudden and preternatural onus on 
176
AORTA.  (Aneurism—Symptoms.)
the vessels:  as, violent passions and emo-
tions of the mind; active bodily exertion;
falls,  blows,  and contusions;  vomiting,
straining at stool, the efforts of parturition,
violent exertion of  the lungs,  excessive
venereal indulgence, &c.  The extreme
liability of prostitutes to aneurism of the
aorta, was long since noticed by Morgagm,
(Epist. XVI. 13.) and  the correctness of
the remark has been  since confirmed by
Testa and Joseph Frank.
   E.  Symptoms and Diagnosis.  In ana-
lyzing the symptoms of aneurism of the
aorta, with a view  to  the formation of a
correct diagnosis, it will be convenient to
divide them into general or rational; and
physical, or such as are revealed by explo-
ration with the hand and auscultation.
   a.  General Symptoms. They are chiefly
such as arise from the  pressure or disten-
sion exercised by the aneurismal tumour
on the parts situated in its vicinity.  The
organs and structures which are liable to
be thus  affected  have been  enumerated
above; and  the remarks there made will
very naturally suggest the most striking
functional disturbance which will be apt to
arise from such causes.  But as most of
these effects are owing to the mechanical
influence of the tumour, it is  evident that
they must be entirely absent during the
early stage of the disease, and will only
make their appearance after the latter has
attained considerable size.  Hence there
are no general symptoms that can indicate
the  existence of aneurism of the aorta
during the first stages of its development;
and daily experience  demonstrates, that
the disease may pass through all its stadia,
attain even a great volume, and finally
terminate by rupture into the  cavity of the
thorax or abdomen,  or some of the organs,
without  giving rise, at any time, to suf-
ficient  disturbance  to awaken  even a
momentary suspicion of the  existing mis-
chief.  Very generally, however, more or
less embarrassment of function  will be
experienced  in those organs  which suffer
from the encroachments of  the  tumour.
When the trachea or bronchi are com-
pressed, the respiration will generally be
difficult, sometimes stridulous; and where
the  tube is  considerably narrowed, the
voice  may  be materially  modified:  in
one case, observed  by Renaud, a species
of egophonism was perceived.   (Journ.
Hebdomad.  II. 3.)  There is often, under
such circumstances, a peculiar  roughness
or hoarseness of the voice, or even partial
or complete aphonia.   Frank relates a
case of a young man at Wilna, in whom
the voice was completely extinct, and who
suffered so much from a sense of suffoca-
tion, that he made signs, with his hand, to
his attendants to open a vein in the arm.
This hoarseness and extinction  of voice '
may arise either from the pressure of the
tumour upon the air passages, or  its en-
croachment upon the  recurrent  nerves.
(Bourdon.)  It is even possible for one of
the bronchi to be thus obstructed by an
aneurismal tumour of  the  aorta,  without
producing the slightest modification of the
phenomena, elicited  by percussion, in the
corresponding lung.   Auscultation, how-
ever, will  discover a remarkable  feeble-
ness or total  extinction of the respiratory
murmur  in the affected organ.   But this
circumstance will be insufficient to demon-
strate the existence of aneurism; for the
same phenomena may be  produced  by
many other causes:  as the  compression
of tumours of a  different kind upon the
bronchus, a contraction of its calibre by
changes of structure taking place within
its substance, or even by spasm of its rami-
fications. Andral reports a case, in which
the right bronchus was so nearly closed
by a thickening of its lining membrane,
that it was scarcely  capable of admitting
an ordinary probe.   The  same difficulty
of breathing and absence of the  respira-
tory murmur may be produced by the en-
croachment  of  the aneurismal  tumour
upon one or both lungs.
   But while all these symptoms may be
developed by aneurism of the aorta, they
may arise from an infinity of other causes.
Hence, taken either individually or collec-
tively, they are altogether  fallacious, and
furnish no positive indication of the ex-
istence of that disease.
   The dysphagia which arises from the
pressure of the  tumour upon the oesopha-
gus, the  pain and  sense  of laceration
sometimes experienced behind the upper
part of the sternum, and which have been
supposed  to  depend  upon  the  forcible
stretching of the nerves, and the peculiar
whispering voice mentioned by Corvisart
as one of the indications of aneurism, are
not entitled to more confidence as diag-
nostic symptoms. They may be produced
by so many other conditions, Jhat no reli-
ance can be placed on them, except when
they are accompanied by other phenomena
of a more positive character.
   The effects which arise from the pres-
sure of the tumour upon the vena  cava
may be  enumerated amongst the symp-
toms of aortal aneurism.   It has been re-
marked above, that  in the  cases observed
by Corvisart and  Renaud, there were
symptoms  of cerebral congestion even 
                      AORTA.  (Aneurism—Symptoms.)                    177

apoplectic in their nature, together with  that his description of the symptoms of
an oedematous condition about the face  aneurism of the aorta was drawn from a
and neck.  In Renaud's case,  in  which  hundred and  thirty-seven cases observed
the vena cava was obliterated, the  super-  by himself, and nearly as many described
ficial veins were turgid, and the blood was  by others;  and it  may be very well re-
returned to the auricle through  the anas-  marked, that there is scarcely a symptom
tomosis between those of the thorax, and  of any  disease of the  thoracic  organs,
the superficial veins of the abdomen. The  which he has not included in the list.
same, or similar phenomena were observed '  When the aneurism occupies the thora-
in the cases  reported by Syme, and Bee-  cic aorta, other symptoms are often append-
vor,  and in  that which occurred  in St.  ed.   There is frequently pain of the back,
Bartholomew's Hospital.   It is  remarked  which is sometimes dull, sometimes more
in Beevor's case, that the veins over the  or less acute;  and when important changes
chest were exceedingly turgid and in " a  have taken place in the bodies of the  ver-
varicose condition;" and in the case at St.  tebraa in consequence of the encroachment
Bartholomew's, " clusters of minute veins,  of the tumour, the pain is often of a boring
almost varicose, were scattered over the  or lancinating character.  There  is  also
chest; and on the back, in addition, there  sometimes a painful sense of  constriction
were several large cutaneous veins."  To  ranging round the inferior part of the  tho-
these symptoms,  may be  added preter-  rax, in the direction of the attachments of
natural venous pulsation in the neck, to  the diaphragm; and in some instances, the
which several writers on this subject have  pain and uneasiness are so strikingly man-
made particular reference. It will always  ifested about  the  epigastric or hypochon-
exist where there  is a communication be-  driac regions, that the disease is liable to
tween the aneurism and the vena cava;  be mistaken for an affection of the stomach
but may  likewise  be produced by the im-  or liver. Through the   kindness  of our
pulse of the former being imparted  to the  friend, Dr. Thomas, we  had  an opportu-
veins. Still these symptoms, like the pre-  nity of examining a  case of  this kind
ceding, may depend  upon disease  of the  within a few months. The individual was
heart and other conditions, and can never  a stout negro man, who  for a year or two
be regarded as affording conclusive evi-  previous to his death had complained of
dence of the  existence of aneurism.      occasional uneasiness in  the  right hypo-
  It  has been remarked by Corvisart,  chondriac region, and had been treated by
that  extreme smallness and irregularity  a skilful physician  for a  chronic affection
of the pulse, its  inequality in the two  of the liver.  At the period of his death,
arms, or its  extinction  in one of them,  he had just been engaged in splitting wood
may be regarded  as  indications of aneu-  in a cellar, and dropped down suddenly
rism  about the arch of the aorta.   It  is  without any premonition. The left cavity
true  that these peculiarities of the pulse  of the pleura  was found distended with
often exist, yet they are perhaps as often  coagulated  blood,  which proceeded from
dependent upon diseases of the heart, or  the  rupture of a  large  aneurism of the
other pathological conditions,  and are,  thoracic aorta situated immediately above
therefore, in  themselves,  entitled  to but  the diaphragm, to the tendinous  portion
little confidence.  A similar remark may  of which the  tumour was intimately at-
be made in relation  to the dull or lanci-  tached.   Indeed,  aneurism of the aorta,
nating pains which  are  sometimes expe-  like some of the diseases of the  heart, not
rienced  behind the  sternum;  pain  and  unfrequently  occasions considerable  con-
numbness of  the  shoulder and  upper ex-  gestion  and enlargement of the liver and
tremity, which sometimes arise from the  spleen, or both, and when the tumour is
pressure  of the tumour on the lower part  voluminous, it may protrude the diaphragm
of the axillary plexus of nerves; violent  downwards, and  with it the  organs in
pulsation of the carotid  and temporal ar-  question, to such  an extent,  as to force
teries; vertigo; disposition to syncope or  them considerably out of their natural  situ-
exhaustion on taking slight exercise; ob-  ation.  The liver may even present, when
fuscation of vision 'ringing of the ears;  explored through the walls of the abdo-
wakefulness; convulsive  motion  of the  men, all the  indications of extreme en-
muscles of the face and extremities; ob-  largement, yet retain its natural volume,
stinate cough; mucous and bloody  expec-  the deception being occasioned by its be-
toration;  epistaxis;  hemoptysis;  and  a  ing forced forward, downward, or laterally,
hundred other symptoms which have been  by a large aneurismal tumour.  Dr. Beatty
enumerated by Joseph Frank and other  has described a very interesting  caise of
writers.   That gentleman, indeed,  states,  this kind, in which, for some  time before 
178                    AORTA.  (Aneurism—Symptoms.)
death,  the liver appeared distinctly  en-
larged, and the tumefaction seemed to in-
crease daily in size. Death was occasioned
by the rupture of  a large aneurismal tu-
mour of the aorta into the cavity of the
pleura.  On proceeding to examine  the
body, it was found that the apparent tu-
mefaction of the  liver had disappeared,
and that that organ, with the exception of
a few indentations upon its convex face,
occasioned by the pressure of the ribs, was
healthy.   The collapse of the aneurismal
tumour  allowed the liver to resume its
natural situation, and of course the sem-
blance of enlargement was no longer per-
ceptible.  (Dublin  Hospital Reports. V.)
  So soon as the tumour attains sufficient
size  to  protrude from  the cavity of the
thorax, or  to deform and destroy the walls
of that cavity,  there can no longer be any
difficulty in recognizing the nature of the
disease.  This  means  of diagnosis, how-
ever, is only applicable in a few cases;
for in a large  majority of instances, the
tumour ruptures, or the disease terminates
fatally in some other way, long before its
development advances so far.
  It  will thus be seen,  from a review of
the  general symptoms of aneurism of
the aorta, that they are all such as are
common to many  other diseases.  How-
ever well calculated they may be, when
taken collectively,  and in  connexion with
the circumstances  of the case, to awaken
a suspicion of the  existence of aneurism,
they can never afford more than presump-
tive  evidence, and are altogether too equi-
vocal without the corroborative indications
to be drawn from  other sources, to war-
rant  a positive conclusion.  In conjunction
with other phenomena, however,  some of
them may occasionally  afford considerable
assistance in arriving  at  a correct diag-
nosis.
  b.  Physical Signs. Preternatural pulsa-
tion  behind the sternum, in the lower part
of the neck, in the carotid arteries, and in
the course of the abdominal aorta, though
not strictly physical signs, may be enume-
rated under this head.  It is a common at-
tendant upon  aneurism, and varies as to
its precise situation and  other  circum-
stances, according to the location of the
disease, and the condition  of the adjacent
parts.   In itself, it is always an equivocal
symptom, as it may be occasioned by  a
disease of the heart, by tumours encroach-
ing  upon  the  aorta, by an extreme state
of nervous erethism of that vessel or of
the vascular system generally, by inflam-
mation and adhesions of the pericardium,
or even a solidification of the lungs and
other thoracic  organs.  It is a common
symptom in extreme anemic states of the
system; and in some cases of that disease
we have seen  it so strongly manifested,
that an inexperienced observer would have
been very liable to suspect the existence
of aneurism.  Aneurisms  of the innomi-
nata, and of the subclavian and  carotid ar-
teries, when they are situated  low down,
are likewise attended with a similar pulsa-
tion ; and Burns, Cooper,  Hodgson, and
others, long since pointed out the difficulty
which is often experienced in distinguish-
ing them from aneurism of the arch of the
aorta.  Still, if with violent pulsation be-
hind the upper part of the sternum, and
other symptoms of aneurism, there be as-
sociated, the smallness, irregularity, and
inequality of the radial pulses above al-
luded to:—or if with a similar pulsation
in the course of the abdominal aorta, there
be  analogous character in the  pulses of
the femoral arteries, some grounds will
exist for suspecting the disease to be  an-
eurism; but additional  evidence will be
necessary to justify a positive conclusion.
But while this  is true of  mere increased
pulsation,  we shall  presently  see,  that
when the character  of the impulse, and
the sounds of the artery,  are accurately
analyzed,  they are  capable  of affording
valuable indications.
  Dullness elicited by percussion in  the
upper part of the chest, though  a common
symptom in thoracic aneurism, is not pe-
culiar to that disease.  A purring tremor,
perceptible when the hand is applied to
the middle or upper part of the sternum,
has been mentioned by Corvisart as an
evidence of the existence  of  aneurism of
the descending aorta. Elliotson likewise
remarks," that a bellows-sound,  or a thrill-
ing sensation given to the hand  only, or
chiefly, when applied above or to the right
side of the cardiac region, may justly give
a strong suspicion  of the disease.  But
neither of these symptoms always occurs;
and both were absent in four cases out of
seven." (Art of distinguishing the various
diseases of the Heart, &c.  p.  35.)  L\en-
nec even affirms, that he had not been
able to distinguish  the purring tremor
before  the  aneurism became  manifest ex-
ternally ; and a similar remark is made by
Hope,  who  represents,  that he had never
found  it perceptible below the clavicle,
except  where  the enlargement was so
great as to extend beyond  the lateral mar-
gins of the sternum, and allow the  tre-
mor to be felt  through  the  intercostal
spaces; or where a sacculated aneurism
had eroded the bones and presented be- 
AORTA. (Aneurism—Symptoms.)                    179
neath the integuments. (Treatise on dis-
eases of the Heart, &c.  p. 417.)  Even
when present it is an ambiguous symp-
tom.  It may depend upon simple dilata-
tion of the  vessel; mucous rhonchus  in
the bronchi; ossification of the valves  of
the heart; or even a rugged and uneven
condition of the inner surface of the aorta,
especially when the  circulation  is much
accelerated.
   Auscultation  furnishes  decidedly  the
strongest—indeed we  may say, almost
the only positive indications of aneurism
of the aorta.  Laennec, who did not con-
sider the stethoscope adequate  to form a
diagnosis in this disease, remarked, never-
theless, that he had sometimes  succeeded
in detecting its existence  by means  of
that  instrument   The phenomenon  to
which  he attached the greatest impor-
tance was, " a single impulse in the situa-
tion of the tumour, louder and more forci-
ble than that of the ventricle, and syn-
chronous  with the pulse."  This  single
impulse can generally be distinguished
from that of the heart which is double, or
consists of a short and a prolonged sound,
the first of which Laennec attributed to
the auricle, and the second to the ventri-
cle.  The latter only is synchronous with
the pulse, and as the auricular sound can-
not be generally  heard in  aneurism, the
ventricular sound  is the only one liable to
be confounded with that occasioned by the
aneurismal tumour.  The latter, however,
can be distinguished from it, by its greater
intensity, as well as by its harshness and
other characters.  Laennec questioned the
sufficiency of this means of diagnosis, ex-
cept in a limited range of cases.   As the
impulse and sound of the heart is gene-
rally diffused  over the whole of the sub-
sternal, and even the entire subclavicular
regions, whenever the cavities of the  or-
gan  are dilated, he  supposed that under
such circumstances,  the  diffused  ventri-
cular impulse might be confounded with
the impulse of an aortal aneurism, while
the feebler auricular impulse  or  sound,
being  extended  as  far as the  aneurism,
might be mistaken for the  impulse of  the
tumour.  It should be mentioned, more-
over, that the aneurism may, under par-
ticular circumstances,  acquire  a  double
stroke  or impulse.   This will take place
whenever the tumour comes  in contact
with either the heart or the surface of the
pericardium; or whenever a solid tumour
or other  firm  medium is interposed  be-
tween  the heart  and the aneurismal sac,
by which the impulse of the former may
 De transmitted to the latter.  Cases illus-
trative of these phenomena have been ob-
served by Graves and Stokes, and Cru-
veilhier.  It is indeed represented by
Stokes,  that the tumour may present a
double stroke without any contact, either
direct or indirect with the heart.
  The possibility of deception  from the
causes enumerated, renders  it necessary
that great caution should be observed in
exploring the chest.   If this  be attended
to, we are inclined to think with Hope,
that " it is unimportant whether the pulsa-
tions be simple or double, for, though dou-
ble,  they may be distinguished  from the
beating of the heart by unequivocal cri-
teria."   He  remarks, that the first or an-
eurismal sound coinciding with the pulse,
is invariably louder than the  healthy ven-
tricular  sound,  and generally  than the
most considerable bellows-murmurs of the
ventricles;  that in  exploring the aneu-
rismal sound from its source  towards the
region of the heart, it is found to decrease
progressively, until it becomes totally in-
audible,  or is lost in the predominance of
the  ventricular sound; that  if the sound
emanated from the  heart alone, it would
increase, instead of decreasing,  on ap-
proaching the  praecordial region:—that
the  second  sound  actually  does  sustain
this progressive augmentation on advanc-
ing  towards  the heart; and as its nature
and rhythm are found to be precisely simi-
lar  to those  of the ventricular diastole
heard in the praecordial region, it is dis-
tinctly identified  as  the diastolic sound.
Hence  the  second  sound  corroborates,
rather than  invalidates  the  evidence of
aneurism afforded by the first; for if both
sounds proceeded  from the heart,  both
 wquld, on approaching it or receding from
 it sustain the same progressive changes
of intensity:—finally, that the aneurismal
 pulsation is a deep hoarse tone, of short
duration, with an abrupt commencement
and termination, and generally louder than
 the most considerable bellows-murmur of
 the heart   It  accurately resembles the
 rasping  of a sounding-board heard from a
 distance; whereas,  the  sound occasioned
 by valvular disease of the heart has more
 analogy to  the bellows-murmur,   being
 somewhat soft and prolonged, with a gra-
 dual swell and fall.  (Loc. Cit. 425.)
   These characters will be observed either
 beneath the sternum or in the dorsal re-
 gion, in thoracic aneurisms.  When the
 disease affects the ascending aorta, or the
 arch, the sounds will be  perceptible in the
 upper portion of the thorax, above  or on
 the  right side of the cardiac region; but
 when it occupies the descending portion 
180
AORTA. (Aneurism — Treatment.)
of the vessel, the strong single  impulse
and sound  will  be most manifest in the
back.   As the natural impulse of the heart
is always feeble  in this region, it cannot be
well mistaken for the sound occasioned by
aneurism, especially if the latter present
the abrupt  hoarse, or rasping  character,
which generally attends it.
  It may be proper to observe, that  even
the sound of the aneurism itself may be
double;  so that  when the stethoscope is
applied,  a distinct  double bellows sound
(Bruit de  Soufflet) can sometimes  be
heard  in the situation of the aneurismal
tumour,—the first of which is synchronous
with the pulse; while the second, which
is louder, takes place during  the disastole
of the ventricle, and is occasioned, accord-
ing to  Elliotson, by a recoil of the dilated
portion of the vessel upon the  blood, and
the consequent propulsion of this fluid into
the narrow  portion of the vessel beyond
the tumour.  (Loc. Cit. p. 35.)  The first
sound, he thinks, proceeds, in like manner,
from the column of blood pressing  from
the dilated into the narrow portion of the
vessel, under the influence of the impulse
communicated to it by the systole of the
ventricle.  The  bellows sound does  not,
therefore, depend upon spasmodic or irre-
gular action of the vessel, as  supposed by
Laennec, but upon the state of  its calibre
and the condition of its tunics.   But, while
the explanation offered by Elliotson may
be true in some cases, there are others in
which the  bellows-murmur seems to pro-
ceed from a different cause.  Thus it has
been  ascertained  by Corrigan,  that in
some cases of aortal aneurism,  this sound
does not  exist as long as the body is erect
or in a position to keep the aneurismal sac
as forcibly distended by the column of blood
as the aorta itself;  but becomes very mani-
fest and distinct as soon as this pressure is
removed  from the walls of the tumour, by
placing the individual, for a few minutes,
in a recumbent position.  This fact, which
he had repeatedly occasion to  verify, he
explains  upon the supposition, that so soon
as the  walls of the  sac are relieved  from
the active distention occasioned by  the
lateral pressure  of the column of blood,
this fluid, in rushing into it, will form di-
verging currents, which will strike against
the parietes, and  excite vibrations,  pre-
senting all the characters of the bellows'
murmur, or  the  purring  tremor adverted
to above.  (Corrigan.  Dublin  Journ. of
Med. and Chem. Sc.  II.  375.)   In some
cases, however, when the sac is large, its
walls thickened,  or its cavity  filled up by
extensive masses of coagula, both the bel-
lows-sound and  the  purring tremor may
be absent and cannot  be  observed  under
any position or condition of the body.  We
think,  however, that there are but few
cases in which a correct diagnosis may not
be formed, by an observance of the indica-
tions detailed above.
  These  observations of  Corrigan  are
particularly important in  relation to the
diagnosis of abdominal aneurisms; for there
the pressure of the column of blood being
the greatest, it will be the more necessary
to place the patient in the horizontal pos-
ture, in order to render the bellows-sound
of an aneurism perceptible.  Fortunately
the disease can generally be distinguished,
in this  region, by strong pulsations, which
present the peculiar thrill of aneurism, and
by other characters which are unequivocal,
even though  unassociated with any indi-
cations of the  bellows-sound.  Still,  it
must not be forgotten, that tumours within
the abdomen, either reposing  upon the
aorta,  or interposed  between it and the
surface, may  often  become a  medium,
through which the pulsations of the vessel
may be transmitted  with  so much  force,
either  to  the  ear or the  hand, that an
abdominal  aneurism might be suspected
where  none exists.   These tumours, how-
ever, are destitute of both the purring thrill
and the bellows-murmur.   Nervous pulsa-
tions of the abdominal aorta may be easily
distinguished from aneurism, by their being
diffused along the whole extent of the ves-
sel; while the pulsation of an aneurism is
greatest at some one point.
  E.   Spontaneous  Cure, and Medical
Treatment. As rules for the treatment of
aneurism can be most advantageously de-
duced from an analysis of the various steps
adopted by nature, in accomplishing a spon-
taneous cure of the  disease,  it  would be
proper  here to enter upon such an analysis,
were it not  that  the  subject  has been
already discussed in the article Aneurism,
and in some of the preceding sections of
the present article.   It may, nevertheless,
be proper  to remark, that  one of the first
steps concerned in the accomplishment of
this salutary result, is  the formation of a
coagulum within the aneurismal sac, which
attaches itself to its  inner surface.  This
is facilitated by cracks and fissures of the
lining  membrane,  or by  a  preternatural
roughness of the inner surface of the di-
luted vessel,  which tends  to  retard  or
entangle the blood, and promote its coagu-
lation ; and the process once commenced,
it may  continue until the whole tumour, or
the entire calibre  of the  vessel,  is com-
pletely obliterated,—the circulation gradu- 
AORTA.  (Aneurism—Treatmen t.)
181
ally finding its way through the collateral
vessels.  Several cases of this kind have
been referred  to under the section on ob-
struction and obliteration of the aorta; and
we have previously remarked, that it has
been rendered probable  by Hodgson, that
sacculated aneurisms of the aorta may un-
dergo a  spontaneous  cure, even  without
obliteration of the vessel taking place.  He
thinks the sac may become gradually filled
up by lamellated coagula, so as to preclude
the further ingress of the blood from the
vessel;  and that,  in course of time, it will
become contracted into a firm tumour, des-
titute of cavity, merely adhering  to one
side of the artery.  In  all cases of spon-
taneous  cure, however, there is besides
simple coagulation of the blood within the
tumour, lymph deposited upon the surface
of the sac, and in the midst of the tissues
forming  its walls,  which,  in  becoming
organized, constitutes one of the most im-
portant  means in the accomplishment of
the cure.
  Coagulation, within the aneurismal tu-
mour, constituting, therefore, one of the
first and most important means adopted  by
nature, in effecting a spontaneous cure of
aneurism, the artificial means resorted  to,
with the same object, should be, as far as
practicable, of a character to produce the
same effect  This indication can be best
fulfilled  by such remedies as are  most
competent to diminish the velocity of the
circulation, without impairing the plastic
properties of the blood, or undermining the
powers of the system.  Unfortunately the
one object cannot be  accomplished, except
at the risk of inducing the very condition
we are anxious to avoid; for, although we
possess  in  blood-letting, diet, &c. ample
means for the fulfilment  of the first part of
the indication, their effects lead necessa-
rily to  such a diminution of the coagula-
bility of the  blood, and to so serious  an
impairment of the vital powers, as to defeat
in a great degree, the end we have in view.
  It has, nevertheless, been long the prac-
tice to treat internal aneurism  by a most
rigid and protracted antiphlogistic course.
This practice, which was first introduced by
Albertini and Valsalva, still has many
adherents,  although there  are  likewise
many who have pointed  out its abuses, and
the mischievous consequences which some-
times arise from  its  improper application.
Valsalva  was in the  habit of confining
his patients constantly  to the recumbent
posture,  and reducing  them so  low,  by
repeated abstractions of blood, that they
were unable to raise their hands from the
   VOL. II.              16
bed.   We  are informed  by Morgagni,
(Epist. XVII. 30.) that after Valsalva had
drawn the  requisite quantity of blood, he
reduced the food from day to day, until he
brought it as low as half a pound of meal
pudding or pap, in the  morning, and  half
that  quantity  for the  evening; with no-
thing else  but water,  in very small quan-
tities, containing, in solution, a little quince
jelly, with powdered  carbonate of lime.
When the individual had been reduced to
a helpless condition by this procedure, the
quantity of aliment was increased by de-
grees, until he took the amount to which
he had been accustomed.
  This practice is no doubt beneficial when
circumscribed within  reasonable  limits;
but when carried to the  extent here re-
presented, we have no hesitation in affirm-
ing,  that it would very generally prove
highly mischievous.  It  is  desirable  to
moderate the  activity  of  the circulation,
as far as is consistent with safety, because,
in proportion as we do so, the formation of
coagula, within the aneurism, will  be pro-
moted. The effects, however, of inordinate
blood-letting, and of too severe a  diet,  it
must always  be  remembered, will be to
give  rise to consequences  diametrically
opposite to what we wish to obtain.  When
depletion is carried too far, it awakens a
kind of convulsive turmoil in the organs
of circulation, which would be altogether
incompatible with the development of those
changes  by which an  aneurism  can  be
cured; and besides, under such  a course
of treatment, the blood is deprived of its
fibrinous properties, becomes exceedingly
thin  and watery, and is consequently less
capable of coagulating than under other
states of the system.
  The first thing to be considered, in  in-
stituting a  plan of treatment for aortal
aneurism, is  the  constitution of  the  indi-
vidual.   If it be feeble, and broken down
by previous disease, copious and repeated
detractions of blood will  be inadmissible,
inasmuch as a resort to them could scarcely
fail to lead to fatal consequences.  But
when the  patient  is  more  plethoric and
robust, and  has  not had his constitutional
powers seriously impaired, blood  may  be
more freely drawn, and the operation re-
peated from day to day, until it has  been
carried as  far as may be  compatible with
safety, and  the effects which are required.
Hope remarks,  that  he  has found  "the
best effect to be  produced with the  least
expenditure of blood, by drawing from xx.
to xxv. ozs. in the first instance,  and re-
peating the bleeding to x.  or xv. ounces 
182                   AORTA.  (Aneurism—ireaimeni.)
within twelve hours; and then taking vi.
or viii. ozs. every six or eight hours, or at
such  intervals  as  to prevent the  re-es-
tablishment of reaction,—a phenomenon
which, by producing an inordinate energy
of the circulation, counteracts the effect
of the depletion." (Loc. Cit. 448.)
  While we are willing that such a course
should be adopted as a general rule, espe-
cially in those whose constitutional powers
have not been seriously impaired, we  feel
assured, that in a large proportion of cases,
blood  must be more sparingly drawn, if we
would not jeopard the life of the patient.
There is, indeed, abundance of evidence to
prove, that too much  depletion, and too
severe a regimen, will often thwart the
fulfilment of  the very objects we have in
view.  The bad effects may, as previously
remarked, either consist in the impairment
of the plastic or cohesive powers of the
blood, by depriving it of its fibrine,—in the
development of that peculiar preternatural
throbbing of the vascular system, which
is so wont to supervene upon copious ab-
stractions of blood; and finally, an enfee-
bling  of the cohesiveness of the coats of
the artery, rendering them  more friable,
and consequently more prone to rupture
under the distending influence of the blood.
The truth of the last inference has been
fully  confirmed by the extensive experi-
ence of Dupuytren, who  has repeatedly
remarked, that internal aneurisms, treated
by Valsalva's method, are apt to increase
more rapidly in size, and finally rupture,—
consequences which  he explains upon the
supposition, that the depletion weakens the
coats of the arteries more than it does the
action of the heart.   (Paillard.  Revue
Medicale, Jan. 1829.)  In  the  case re-
ported by Beatty, already  referred to.—
in one published by Proudfoot, in  the
Edinburgh Medical and Surgical Journal,
and in others observed by Stokes and
Graves, (Dublin Journal. V. 431.), a ma-
nifest amelioration  of the disease was pro-
duced by a change from a  very scant, to a
more  generous diet  Still this change
should never be made,  except where  it is
absolutely demanded by the  prostration of
the vital  powers, either induced by dis-
ease, or by previous depletion and absti-
nence; and even then, it must be done
gradually, and in such manner as not to
excite the heart and arteries, by render-
ing the blood suddenly too rich  in plastic
and stimulating properties.
  As regards the method of drawing blood,
there is some difference of opinion.  Mor-
gagni long since cautioned against bleed-
ing to syncope, in cases of internal aneu-
rism, representing that death sometimes
takes place; and Hodgson, adopting simi-
lar views, (in which  he is followed by
Bertin and Bouillaud, Hope, and others,)
remarks,  that he  has seen  the syncope
protracted to an alarming period, and that
a coagulum is apt to form in the aneuris-
mal tumour, which, on recovery from the
fainting fit, will prevent the blood from
resuming  its usual route, and  give  rise to
fatal  embarrassment  of the  circulation.
Chomel, on the' contrary, advises to seat
the patient in an upright posture, and bleed
him from  a large orifice, until  syncope is
induced,—in order that the blood, during
its quiescent state, may coagulate better in
the aneurism, and thus lay the foundation
for its obliteration.  (Diet, de Med. 2d edit.
III. 418.)   The  propriety of this practice
may be questioned; and, if the view taken
by Hodgson be adopted, it cannot be con-
sidered as entirely exempt  from danger.
The gradual abstraction of blood will  pro-
bably be  found  more  useful,  and should
consequently  be preferred; but even  this
must in general, be cautiously resorted to,
when the  individual is  much affected with
palpitations.
  When general bleeding has been pushed
as far as the  strength of the patient  will
admit the application of leeches will often
prove highly serviceable.   But, when the
tumour protrudes externally, and elevates
the skin,  they should never  be applied
directly to the part, on account of their
liability to excite ulceration or sloughing
of the skin, which might hasten the fatal
termination of the disease.
  On  the subject of  internal remedies,
much need not be said. Mild saline ape-
rients will be proper from time to time, to •
keep the  bowels soluble and quiet  irrita-
tion ;  and, with the latter view, together
with the object of exciting the discharge
by the kidneys, the nitrate or  acetate of
potassa, or some of the other mild  saline
diuretics,  may be employed.
  The power which digitalis possesses, in
controlling the action of the  heart  and
arteries, has led to its general employment
in this disease.  It is no doubt capable of
doing much good, when prudently admin-
istered ; but when given in large doses, or
so rapidly introduced  as  to  exercise its
prostrating influence, it may prove fatal,
as represented by Hope, by exciting syn-
cope.  It  should, therefore, be given in
very small doses, repeated at proper inter-
vals, care  being taken to observe its effects
very closely.   The same remarks will ap-
ply to hydrocyanic acid,  prunus  lauro-
cerasus, colchicum, hyoscyamus, stramo- 
AORTA.  (Aneurism—Treatment.)
183
 nium, and all the kindred articles, which
 may  sometimes be resorted to as pallia-
 tives.
    Various remedies,—mostly  of the as-
 tringent kind, have been employed with
 the object  of improving the crasis of the
 blood, and thus rendering it more liable to
 coagulate.   Of these, the acetate of lead
 is the most popular.  It has been  used by
 Dupuytren, Laennec, Bertin and Bou-
 illaud, Joseph Frank, Hope, Copland,
 and others, with some advantage.   Hope
 recommends it to be given in half-grain
 doses gradually increased to a grain, com-
 bined with half a  grain of opium, three or
 four times a day.   Its tendency to excite
 gastric irritation or colic, he says may be
 obviated by mucilaginous diluents, and an
 occasional  dose of castor oil. The mineral
 acids have also been employed, but we are
 not aware that they have been  of any ser-
 vice ;  nor is it certain that alum, or the
 preparations  of  iron  recommended  by
 Kreysig (Die Krankheiten des Herzens.
 2 Theil. 744.) are more entitled to confi-
 dence.  Copland, however, remarks, that
 in cases attended  with palpitation of the
 heart, or  inordinate pulsation  of the tu-
 mour, he has prescribed  the sulphate of
 zinc,  and the sulphate  of alumina, gene-
 rally  combined with small doses of cam-
 phor  and  hyoscyamus,  with considerable
 benefit as palliatives.  (Diet,  of Pract.
 Med.  I. 78.)
   When the tumour protrudes beyond the
 walls  of the thorax, it  has been recom-
 mended  by  some practitioners to apply
 ice,  cold astringent lotions, &c, to  the
 part.  There is reason to suppose that good
 effects might be realized from the applica-
' tion  of ice, if it were possible  for the pa-
 tient  to endure it for a sufficient length
 of time. But generally it creates so much
 pain and suffering that it cannot be long
 continued,  and  its mere temporary em-
 ployment can be of no great avail towards
 effecting a cure. When there are pain and
 inflammation in the tumour, however, cold
 and anodyne lotions maybe advantageously
 resorted to as palliatives.
    In  carrying out the treatment, perfect
 quietude of both mind and body must be
 enjoined.  The patient should be confined
 to the horizontal  posture, and  prohibited
 strictly from  the use of everything which
 can tend  in  the slightest degree to  ac-
 celerate the circulation.   The diet should
 be at  first altogether fluid, and as bland as
 possible; and when an  attempt is to be
 made  to effect a radical cure,  it must be
 reduced in accordance with the principles
 already suggested.  Should  any amelio-
 ration be  experienced under the reduc-
 tion, the system should be persevered in
 some time longer;—but when no benefit
 accrues, or when the disturbance of the
 patient and the impairment of his health
 are increased  by the treatment,  and the
 dietetic  regimen, they should be imme-
 diately abandoned,  and  the patient put
 upon a more generous diet
   After all, it  must  be  confessed, that we
 have but slender grounds to hope  for com-
 plete success  in  the treatment of aortal
 aneurisms by any system of practice.  That
 cures have sometimes been effected spon-
 taneously, there is  too much evidence to
 allow us  to  entertain a  doubt; and that
 some cases have  been successfully  com-
 bated by various modifications of the prac-
 tice of Valsalva and Albertini,  must
 likewise be granted.  But if a careful an-
 alysis of all the facts and statements be
 made, it will probably be found, that many
 of the reputed cases of success have not
 been examples of aneurism, but of pulsa-
 tion of the aorta from  other causes, or
 glandular or other tumours developed upon
 the course of that vessel.  True aneurism
 of the aorta of considerable size, is proba-
 bly  never obliterated,  when  it  assumes
 either the fusiform  or cylindroid shape;
 and our principal hope of success must be
 confined to those cases of sacculated false
 aneurism,  which  are  rough  and uneven
 upon the inner surface, and communicate
 with the cavity of the vessel by a narrow
 opening.

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following isolated cases, &c, which are contained
in the Journals we have at  hand:
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Med. Recorder.  XIV. 239.   Philadelphia Journ.
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IX. 508., XXIV.  262.  Dublin Journal.  II. 448.
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58. 1833.  Gazette Medicale,  for March, 1833.
in. 874.
  For numerous  authorities and cases amongst
the earlier writers, see also Ploucquet, Biblio-
th e/h Medico-Practicae et Chirureicae, &c. I. 332.
Xrfbing. 1793.

'  \ 5. Wounds of the Aorta.  In  wounds
penetrating the thorax  and abdomen, the
aorta, in  common with  the  other organs
contained within those  cavities, is  liable
to  be injured; but  as  such  wounds  are
almost  always  immediately  fatal,   they 
AORTA. (Wounds.)
185
 seldom become objects of surgical treat-
 ment.  It sometimes happens, nevertheless,
 that death does not  ensue so promptly;
 and cases  have been reported,  in  which
 individuals have survived wounds inflicted
 upon the aorta for a considerable period.
 Such instances, it is true, are exceedingly
 rare; yet the fact that such an occurrence
 is possible, is important; because it indi-
 cates the necessity, when a suspicion exists
 that such an accident has been sustained,
 of employing  those means which are cal-
 culated to afford the individual the best
 security against a fatal termination.
   A6 a brief abstract of the most remarka-
 ble cases of wounds of the aorta has been
 given by Berard, in an article on that
 subject, in the Diet, de Mid. III. 421., we
 cannot do better than present a summary
 of the most interesting facts which he has
 selected.   The first is a case published by
 Sassard, in the Journal de Medecine,
 XLVI. 435.  In an individual who died
 on the sixth day of a wound of the thorax,
 it was found that the aorta had been wound-
 ed, a little above  its exit from the  left
 ventricle.  Lerouge  has reported a case,
 in which death did not take place until the
 eleventh day, although the instrument  by
 which the wound  was inflicted,  passed v
 through both the aorta and the right auri-v
 cle of the heart   (Recueil d'Observat.
 Chirurg. de Saviard.)  A still  more re-
 markable case is published by Pelletan.
 (Clin. Chirurg. I. 92.)  A  young officer
 was brought to Hotel Dieu, whose thorax
 had been transfixed in a duel, with a fenc-
 ing foil.  The weapon had entered a little
 above  the right nipple, and came out at
 the left side of the breast.  No accident
 occurred during the first  fortnight; but
 at the expiration of  this  time,  he com-
 plained of pain about  the  kidneys, which
 wa3 quieted by the bath.   After this  he
 recovered so far as to be able to walk with
 the other  patients.   But   in  about two
 months, deformity of the spine took  place,
 the respiration  became  exceedingly labo-
 rious, and he died  suffocated.  The right
 side of the thorax was found full of coagu-
 lated blood, and the aorta, a little  above
 the pillars of the diaphragm, presented an
 opening of the size ofa writing-quill.
   It is even possible for a slight wound of
 the aorta to be followed by the development
ofa false consecutive aneurism. The only
recorded case of this  kind is one reported
by Guattani (de aneurismatibus),  which
occurred in a servant, who survived eight
years after the receipt of the injury.  The
wound was inflicted by a sharp instrument,
which  penetrated  the lumbar region, in
                 16*
the vicinity of the spinous processes.  The
principal  inconvenience that was experi-
enced, after  the wound had healed, was
acute pain in the loins; and when death
took place, it was found that a large aneu-
rismal sac existed upon the aorta, on a level
with the cicatrix, although the coats of the
artery in  the vicinity presented no traces
of atheromatous or calcareous degenera-
tion.
  When we reflect upon the great size of
this vessel, it is  manifest that any wound
not to prove immediately fatal,  must  be
exceedingly small.  Even a puncture  of
very limited size, transfixing its walls, will
be sufficient  to give rise to fatal hemor-
rhage ; and an incised wound must neces-
sarily prove fatal within a few moments
of its infliction.   It is possible here, how-
ever,  as in some cases of wound of the
heart when the  puncture is very small,
for the opening to be closed up by a coagu-
lum, especially if syncope should take place
at the period of the infliction of the injury,
and thus prove a means of protracting the
fatal termination.   The cases referred to
above, render it not  improbable that  a
cure might sometimes be obtained, under
favourable circumstances, and by judicious
treatment  Such an event, however, can
seldom be expected; and even in contused
and lacerated wounds of the  aorta, the
same unfortunate issue always takes place,
because the vessel is  so large that contu-
sion and laceration do not afford  the pro-
tection against  hemorrhage which  they
often do in vessels of smaller size.
  If it were  possible to discover a wound
of the aorta not immediately fatal, it would
be proper to confine the individual for
months in a  perfect state of immobility,
both of body and mind;  to abstract blood
from day to day, or at longer intervals, as
far as might be compatible  with safety,
and to institute all those  means which are
proper to subdue the activity of the circu-
lation.
  Bibliography.—Berard.   Plaies de I'Aorle.
in Dictionnaire de Medecine, 2d edit. III. 422.
Paris, 1833.
  5 6.  Ligature of the Aorta.  The facts
which have been detailed in the section
treating of obstruction and obliteration of
the aorta,  prove conclusively, that the clo-
sure of this great vessel does not  necessa-
rily suspend the  circulation in  the lower
extremities.  The same fact has  been es-
tablished by experiments which  have been
repeatedly made on animals; from which
it appears, that in them, even a  ligature
may be applied to the aorta without lead-
ing  to fatal consequences,—the  capacity 
186                          AORTA.  (Ligature.)
of the collateral circulation becoming, un-
der  such circumstances, sufficiently in-
creased  to supply the  members,  and to
compensate for the obliteration of the main
trunk.  The daring intrepidity of modern
surgeons has even prompted them to prac-
tise  this operation on the human subject;
but although it has  now been performed
three times, the results have been such as
to be far from encouraging.  All  the cases
terminated fatally within a few hours, al-
though  the operation was achieved with-
out difficulty.
  The first operation of this  kind was per-
formed by Sir Astley Cooper, in a case
of very large aneurism of the iliac  artery,
which sloughed and  nearly destroyed the
patient by hemorrhage.   He first opened
the aneurismal sac above Poupart's liga-
ment in order  to ascertain if the aorta
could not be. secured near its bifurcation
without dividing the peritoneum. Finding
this  impracticable, he made an incision
three inches in length,  along the linea
alba,  commencing above the umbilicus,
and ranging round it, to terminate below.
He then passed  his finger  between  the
convolutions of the intestines, down to the
spine, where the artery was felt beating,
and  scratching  through the peritoneum
with his nail, the finger was passed  be-
neath the vessel,  and a blunt  aneurismal
needle armed with a ligature was con-
ducted round it guided by the  finger.
The ligature  was then cautiously drawn.
The patient survived the operation only
forty hours, when he  died apparently from
exhaustion. (Cooper  and Travers' Sur-
gical Essays. 1.114.) Dissection revealed
no peritoneal inflammation, and the tem-
perature of the limb on the side on which
the iliac artery was sound, was ninety-six
after the operation.
  Mr. James, of Exeter, performed  the
same operation in 1829, on an individual
labouring under aneurism of the iliac ar-
tery, for which he had previously applied
a ligature on the distal side of the tumour,
according to the method of Brasdor.  As
the tumour threatened to burst, he  resolv-
ed, as the last chance, to apply a ligature
to the aorta. The operation was performed
in the same  manner  as  in the preceding
case; but  the individual survived only
three hours  and a  half. (Medico-Chir.
Trans.  XVI.  Pt 1.  1830.)
  The third operation was performed by
Dr. Murray, at the Cape of Good Hope,
on the 28th  of Feb. 1834.  The subject
was a Portuguese seaman, aged  thirty-
three, of spare  habit;  and the circum-
stances  of the  case  were  analogous to
those in the patients operated on by Sir A.
Cooper and Mr. James—the  disease be-
ing iliac aneurism.   The ligature was ap-
plied immediately  above the bifurcation
of the aorta, and was followed  by a sub-
sidence of the  temperature of  the  right
ham to 89£°, that of the axilla being 9>-'.
The  patient survived the operation. not
quite twenty-three  hours.  (Lond. Med.
Gazette, p.  t5. Oct. 1834.)
  So far then, as the results obtained on
the  human  subject  by this  formidable
operation  are  concerned, there  is but
little reason to hope, that the  applica-
tion  of a ligature to the aorta, either for
the cure of" aneurism,  or  for other pur-
poses, can ever be successful.  It has been
supposed by Cooper and others, that if
the operation could be  performed at an
earlier  period,   the chances  of success
would be very much increased. The prin-
cipal difficulty seems to be the inadequacy
of the collateral circulation to compensate
for  the obstruction  of the main current
through the aorta. But when it is remem-
bered, that  in  the  cases of spontaneous
obliteration of this vessel which have been
detailed above,  the  collateral anastomosis
wasTound sufficiently capacious to obviate
this difficulty, there would, at first sight,
seem to be no reason why the same pro-
vision should not suffice, when a ligature
is applied.   The results  of the numerous
experiments made by Cooper, Beclard,
Pinel Grand-Champ, and others,  show
conclusively, that in domestic animals the
application  of a ligature to the aorta can
be practised with complete success, and
if things were  equal in  them and in the
human subject, the same  success ought to
be obtained in the latter,  although the re-
sults  of experience, thus far, do not seem
to justify such a  conclusion.
 This reasoning, though apparently plau-
sible, is far from being conclusive.  In the
first  place,  the parallel between sponta-
neous obliteration, and that which is pro-
duced by ligature,  is not  perfect.   The
first  takes place gradually, and in propor-
tion as the obstacle  to the passage of the
blood through   its   natural channel in-
creases, the collateral vessels become by
degrees dilated,  so that by the time com-
plete closure takes place,  the numerous
anastomoses  formed  between the inter-
nal mammary and  epigastric arteries,—
the intercostals,  lumbars, circumflex iliac,
&c, are sufficiently dilated,  to furnish
an  adequate  supply to  meet  the  de-
mands of the lower extremities.  When
a ligature is applied, on the contrary, the
interruption is sudden; the collateral ves- 
                             AORTA.

eels have not time to dilate, and  before a
sufficient quantity of blood can  find its
way through these  numerous  channels,
death must take place.  The experiments
made on animals are not conclusive;  for,
independently of their collateral  circula-
tion being freer than that of man, they
bear injuries with greater impunity,  and
possess resources which  better  enable
them to ward off their bad effects.
  From all these considerations, we think
the operation  in  question ought never to
be performed.   It is  certainly the duty of
the surgeon to avail  himself of every pos-
sible means of  prolonging human life, but  _
no circumstances can justify a resort to a
painful and hazardous operation, which
promises no prospect of a successful issue.
With  these impressions, we shall not de-
scribe the different procedures which have
been devised for applying a ligature to the
aorta,  but  merely subjoin, that it may be
done  either by making an incision in  the
course of the  linea alba, as practised by
Sir Astley Cooper and Mr. James, or by
dividing the walls of the  abdomen in the
space between the margin of the ribs  and
the crista of the ilium, afterwards detach-
ing the peritoneum  from  the psoas mus-
cles, as was done by Dr. Murray.
  *! 7. Rupture of the Aorta.  In speak-
ing of the pathological characters of chro-
nic aortitis, it was remarked,  that  the
effect of that disease is sometimes to give
rise to such a friability,  softness, or de-
generation of the coats of the aorta, as to
predispose them to terminate in rupture of
that vessel. This termination is common in
aneurism, but occasionally takes place in-
dependently of that disease.  It may oc-
cur in any portion of the vessel,  but  that
which is included within the pericardium
is most liable to such an accident, for reasons
already assigned. In some cases, the rent
is confined at first to the internal and mid-
dle coats,  the  cellular coat resisting for
a time,  and finally yielding,  in conse-
quence of some violent effort or the gra-
dual influence of disease; but occasionally
the whole of them  give  way simultane-
ously, and the  individual falls down dead,
in consequence of the  sudden extravasa-
tion of blood.  The artery may also be
opened by ulceration; by the influence of
calcareous scales upon the adjacent  por-
tion of its tunics; by atheromatous degene-
ration, &c.  When it is the consequence
of a rent, the solution of continuity may-
be either longitudinal, oblique, or circular;
and sometimes It presents a different di-
rection in the internal and middle, and the
external tunics.
(Rupture.)                          187

   Cases of this accident, though not very
 common, are not unfrequently observed.
 We  have s«en  two examples in  bodies
 brought in for dissection. In one of them,
 the rent occupied the abdominal aorta, and
 took  place  in consequence of calcareous
 degeneration of the coats of the aorta.
 The  other was seated in that portion of
 the vessel which is included in the pericar-
 dium, and seemed to have resulted from
 a preternatural  friability of the  tunics.
 Ploucquet refers to an instance, in which
 rupture took place in consequence  of a
 blow on the hypochondrium. (Ephemerid.
 de Nat. Curios. Dec. III. Ann. ii. Obs. 70.)
 A case is reported by Moroagni, of an in-
 dividual who had been long affected  with
 syphilis.  The  aorta ruptured within the
 pericardium  while  he  was ascending a
 flight of stairs (Epist. LIH. 7.); and in the
 same Epist. No. 35., another example is
 recorded, in which a rupture  of the aorta
 was occasioned by a blow on the back.  A
 case is published by James, in which rup-
 ture took place in a healthy seaman, while
 in the act of jumping out of his hammock
 (Lond. Med. and Phys. Journ.  XVIII.),
 and Dr. Elliotson mentions two instances,
 both  in females, in which the aorta was
 ruptured within the pericardium.  In one
 of them, the accident took place in the
 act of stooping.  (Lond. Med. and Surg.
 Journ.  II.  364. 1833.)  He  also  alludes
 to another, delineated in Mr. Allcock's
 plates. In a case reported by Arnott, the
 rupture was  occasioned by a  fall  from  a
 scaffold (Lond. Med. and Phys.  Journ.
 LVIII. 19.), and in the same work, p. 15.,
 another example is detailed by Rose, in
 which the coats of the  artery were ex-
 tensively  diseased.  In  an instance re-
 corded by  Hume, in the  Glasgow Medi-
 cal Journal, IV. 148., the rupture, as in
 James's case, was occasioned by the exer-
 tion  of getting out of bed. (Copland. Loc.
 Cit.  78.)  The most interesting examples
 of this lesion are, however,  two which
 have been reported, the first by Laurencin
 (Archives Gin. VI. 301.), the second by
 Leger. (Diet, de Mid. III. 424.) In these
 cases, the  rupture was  occasioned  by  a
 fragment of bone impacted in  the  oeso-
 phagus.
    For the description  of the  nervous af-
 fections of the aorta, we must refer to Ab-
 domen, pulsations of.

   Bibliography.—Besides the above references,
 see—
   P. II. Berard.   Art. Rupture de  I'Aorte, in
 Diet de Med. 2d edit III. 424.
   Copland.  Diet, of Pract. Med. Pr.I. p. 7ft 1833.
                         E. Geddings. 
188                        APATHY.—APHELXIA.
   APATHY. (From o priv. rta0o5, affec-
 tion.) arfafoia, Gr.; Apatheia, Lat.;  Apa-
 thie, Fr. A deadness of the moral feelings,
 or immobility from impressions which vio-
 lently excite most  persons.  It  may de-
 pend on the organization, and is often the
 appanage of the  lymphatic  temperament.
 Not unfrequently it  results from long con-
 tinued violent excitement, and various ex-
 ternal,  physical, and  moral causes.   Its
 occurrence in diseases is of unfavourable
 import indicating a serious  lesion of the
 nervous system.                 I.  H.
   APEPSIA. (From a priv. and 7titys, coc-
 tion.) Indigestion (q. v.).        I.  H.
   APERIENT.  (From aperire, to open.)
 Aperiens,  Aperitivus, Lat.;  Aperitif, Fr.
 During the prevalence of the mechanical
 doctrines, diseases were ascribed to an ob-
 struction or contraction of the vessels, and
 this term was then employed to designate
 a class of medicines supposed to have the
 power of opening the canals or passages of
 the body.   These remedies were divided
 into deobstruents, resolvents, attenuants,
 and  incisives, according as they were be-
 lieved to act by dilating the vessels or by
 diluting their contents.  As thus  defined,
 and this definition is sustained by its ety-
 mology, such  a class is purely imaginary.
 At present the term is employed only as
 synonymous with Laxatives (q. v.). I. H.
   APHELXIA. (From a$t%xu, I abstract.)
 Revery.  This  is defined by Dr. Good,
 to be an " inactivity  of the attention to the
 impressions of surrounding objects during
 wakefulness."   He makes three species
 of it: 1. A. socors,  absence of mind; 2.
 A. inlenta, abstraction of mind; 3. A. oti-
 osa,  brown study.   The following is Dr.
 Good's  graphic description of these spe-
 cies, as  given in his  Study of Medicine.
   Sp. 1. A socors, absence of mind; truant
 attention;  wandering fancy; vacant or va-
 cillating countenance.
   This  is  an  absence  or vacuity of mind,
 too common at schools and at church; over
 tasks and  sermons; and  there  are few
 readers, who have  not frequently  been
 sensible of it in some degree or other.
  In reading books in which we are totally
 uninterested, composed in a tedious and re-
 pulsive  style, we are almost continually
 immersed in this species of revery.  The
 will does not  exert its power; the atten-
 tion is suffered to wander to  something of
 stronger attraction;  or  the imagination
 is left  to  the play  of its own nugatory
 ideas; and, though we.continue  to read,
we have not the smallest knowledge of the
argument before us: and if the subject to
 which the train of our thoughts is really
directed, be of a striking ludicrous char-
acter, we may possibly burst into a laugh
in the middle ofa discourse of great gravity
and seriousness, to  the  astonishment of
those around us.
   This is a common case, and may lead to
great embarrassment.   We  have  never-
theless  thus  far supposed, that  the  will
does not exert its power, and sufficiently
rein in the attention to the subject address-
ed  to  it  It not unfrequently  happens,
however, that the will, for want ofa proper
habit has lost its power,  either wholly, or
in a very great  degree,  and  cannot with
its  utmost energy, exercise a due control
over the attention; and it also happens in
other cases, from a peculiarity of tempera-
ment, or morbid state of body, that the fac-
ulty of the attention itself is so feeble, that
it is incapable of being  steadily directed
for more than a  few minutes to any object
of importance whatever, with all the effort
of the will to give it such direction.
  The mind, under either of these condi-
tions, is  in a  deplorable  state for all the
higher  purposes of reflection and  know-
ledge, for which by its nature  it is intend-
ed ; since it is upon  the  faculty of atten-
tion that every other faculty is dependent
for its vigour and expansion:  without it
the  perception  exercises itself in vain;
the memory can lay  up no store of ideas;
the judgment draw forth no comparisons;
the imagination must become blighted and
barren ;  and  where  there  is no attention
whatever, the case must  necessarily verge
upon fatuity.
  In early life,  the attention, like every
other faculty of the mind, is  weak and
wandering, is often caught with difficulty,
and rarely fixed upon any thing.   Like
every  other  faculty, however,  it  is ca-
pable of being strengthened and concen-
trated ;  and may be  made to  dwell upon
almost  any  object  proposed.   But  this
is a work of  time, and forms one of the
most important parts of education: and, in
the course of this  discipline, it should not
be forgotten,  that the faculty of attention,
when it first shows itself, is more readily
arrested by some subjects, than by others,
and that it is hence of great moment to
ascertain those subjects, and to select them
in the first instance.   The habit is what
is chiefly wanted, and the quicker this is
acquired, the more time we gain for trans-
ferring the same  habit to other and per-
haps more valuable  purposes  afterwards.
  This is a point seldom  sufficiently con-
sidered  in the course of education; and,
for  want of such  consideration, far more
than half the  time of many boys becomes 
APHELXIA.                              189
an entire blank, and is lost, and  not a few
suffered to remain blockheads in the par-
ticular department to which their hours of
study are directed, who  might discover a
considerable capacity and genius,  if the
department were changed  for  one more
adapted to their  own taste, or, in  other
words, more attractive to their attention.
  There is a very singular instance of ha-
bitual absence of mind  related  by Sir A.
Crichton, in a  young patient under the
care of Dr. Pitcairn and himself, which,
though some other  circumstances appear
to have combined with it is ascribed  con-
siderably to the error of education we are
now speaking of, that of not duly studying
the peculiar bent of a mind  in many re-
spects singularly constituted, and drawing
forth and strengthening the faculty of at-
tention, which was in an especial degree
weak  and  truant, by an employment  of
such objects and pursuits as were most al-
luring.  This patient was a  young gen-
tleman of large fortune, who, till the age
of twenty-one,  and  he does not seem  to
have been much more at the time of de-
scribing his case, had enjoyed a tolerable
share of health, though of a delicate frame.
In his disposition,  he was gentle and calm,
but somewhat unsociable.  His absence of
mind was  extreme, and he  would some-
times willingly sit for a whole  day with-
out moving.  Yet he had nothing of me-
lancholy belonging  to him;  and it  was
easy to discover by his countenance, that
a multiplicity of thoughts were constantly
succeeding each other in his imagination,
many of which were gay and  cheerful;
for he would heartily laugh at  times, not
with an unmeaning  countenance, but evi-
dently from mental merriment.  He was
occasionally so strangely inattentive, that,
when  pushed  by some want which he
wished to express, if he had begun a sen-
tence, he would suddenly stop short after
getting half-way  through it, as though he
had  forgotten  what else he  had to say.
Yet when his attention was roused, and he
was induced to  speak,  he  always ex-
pressed himself in good language and with
much propriety;  and if a question were
proposed to  him,  which  required the
exercise of judgment,  and  he could  be
made to attend to it, he  judged  correctly.
It was with difficulty he could be made to
take any exercise;  but was at length pre-
vailed  upon to drive his  curricle, in which
Sir Alexander at  times accompanied him.
He at first could not be  prevailed upon to
go beyond half a mile ;  but in succeeding
attempts he consented to go farther.  He
drove steadily, and  when about to pass a
carriage, took pains to avoid it:  but when
at last he became familiarized with this
exercise,  he would often  relapse  into
thought, and allow the reins to hang loose
in his hands.  His ideas seemed to be for
ever varying.   When  any  thing came
across his mind which excited anger, the
horses  suffered for it; but the spirit they
exhibited at such an unusual and  unkind
treatment made him soon desist, and re-
excited  his  attention to his  own  safety.
As soon as  they were  quieted, he would
relapse  into  thought:  if  his ideas were
melancholy, the horses  were allowed  to
walk slow;  if they were  gay and cheer-
ful, they were generally encouraged to go
fast.—Of Mental  Derangement,  vol.  I.
p. 281.
   Perhaps, in this  case, something  might
have been owing, as supposed  by Sir A.
Crichton, to an  error in the mode of edu-
cation ;  but the chief defect seems to have
been in the  attentive  faculty  itself, and
its labouring under a natural imbecility,
which no mode of education could entirely
have removed.  We have had frequent oc-
casions to observe, that the powers of the
mind vary in different individuals as much
as those of the body : and we  have already
offered  examples of  weak  or diseased
judgment, weak or  diseased perception,
and weak or vehement imagination.   In
the case  before  us, the  mental  disease
seems to have been chiefly confined to the
faculty of attention ;  and we shall present-
ly have to notice a similar imbecility of
the memory, and even of all the  mental
faculties conjointly.
   Sp. 2. Aphelxia Intenta.—Abstraction
of mind.   The attention  wound  up and
riveted  to a particular subject;  with sym-
pathetic emotion of the  muscles and fea-
tures connected with its general drift.
   In this species, the faculty of attention,
instead  of being feeble,  or contumacious
to the will, is peculiarly strong, and vehe-
mently  excited, and acts in perfect co-
operation  with the  will  itself.   And, in
many  instances,  the  sensorial  energy
maintained  is so great, and  demands  so
large a supply of sensorial power as appa-
rently to exhaust the entire stock, except
indeed the reserve, which is  in almost all
cases instinctively kept back for the use
of the vital  or involuntary organs.  And
hence, all the external senses remain in a
state  of torpor, as though drawn upon for
their respective contributions of sensorial
power in support of the predominant me-
ditation ; so that the eyes do not see, nor
the ears hear, nor  the flesh feel; and the
muser may be spoken to, or  conversation 
190
APHELXIA.
 may take place around him, or he  may
 even be struck upon the shoulders, with-
 out any knowledge of what  is occurring.
   Abstraction of mind may be produced
 by various  causes, but the following are
 the chief, and form two distinct varieties:
   a Aphelxia a pathemate : from some
 overwhelming passion.
   |3 Aphelxia a studio: from intense study.
   Of the first variety we have already of-
 fered abundant examples in the two pre-
 ceding genera: and especially in the cases
 of ungovernable joy  or rapture, grief and
 despondency: under the influence of which
 the affected person is often as much lost
 to the world around  him, as if he were in
 a profound sleep and  dreaming; and only
 hears,  sees, and  feels the  vivid train of
 ideas that possess themselves of his mind,
 and  rule it as a  captured  citadel.   To
 these alone  the attention is directed: here
 it exhausts all its power, and the will con-
 curs in the  exhaustion; insomuch that the
 patient is said in some cases to have stared
 at the meridian sun without pain.—(Blu-
 menb. Bibl. I. p. 736.)  And in others to
 have been undisturbed by the discharge ofa
 cannon.—(Darwin, Zoonomia, III. I. ii. 2.)
   We meet with like proofs of this variety
 of revery in many cases of intense  study,
 and especially upon  abstract subjects, as
 those of pure mathematics,  in which all
 the  reasoning and  more serious faculties
 of the mind, as the perception, the memo-
 ry, and the  judgment as well as the at-
 tention, are  jointly  called into action, and
 kept equally upon  the stretch.  Of the
 power of this variety  of revery in render-
 ing an individual torpid and  almost dead
 to all around him, we have a decided  in-
 stance  in Archimedes at the time  of his
 arrest.   When the Roman army had at
 length taken Syracuse by stratagem,  which
 the  tactics  of this  consummate  engineer
 prevented them  from  taking by force, he
 was shut up in his closet, and so intent on
 a geometrical demonstration, that he was
 equally insensible to the shouts of the vic-
 tors, and the outcries of the vanquished.
 He was calmly drawing the lines ofa dia-
 gram when  a soldier abruptly entered his
 room, and  clapt  a sword to his throat.
 "Hold,  friend," said  Archimedes,  "one
 moment, and my demonstration  will be
 finished." The soldier, surprised at his
 unconcern at a time of such extreme peril,
resolved to  carry him before Marcellus;
but as the philosopher put under his  arm a
 6mall box full  of spheres, dials, and  other
 instruments, the soldier, conceiving the box
 to be filled with gold,  could not resist the
temptation, and killed him on the spot.
   Sp. 3.  Aphelxia Otiosa.—Brown-study.
 Leisurely listlessness; voluntary surrender
 of the attention and the judgment to the
 sportive vagaries of the imagination: qui-
 escent muscles;  idle  gravity of counte-
 nance.
   The attention is equally summoned into
 action and dismissed  at the command of
 the will.   It is summoned in the last spe-
 cies :  it is  dismissed,  when a man volun-
 tarily surrenders  himself  to  ease  and
 listlessness of mind; during which period,
 moreover, in consequence of this indul-
 gence in general  indolence, the external
 senses themselves unite  in the mental
 quiescence, and a smaller portion of nerv-
 ous energy is probably generated for the
 very reason that a smaller portion is de-
 manded;  and  hence   the  active senses
 without are as vacant and unstrung as the
 active senses within,  and  as  blunted to
 their respective stimuli. The first playful
 ideas that float over the fancy in this case
 take the lead, and the mind relaxes itself
 with their easy and sportive flow.  It is
 the sludium inane of Darwin, (Zoonom.
 III. I.  ii. 2;  and again, IV. II. iv. 2.) who
 seems, however, to have in  some degree
 misapplied the name, or to have confounded
 the aberration with that of ecphronia or
 alusia.  Cowper has admirably described
 it.  (Task, book IV.)
   In the  indolent  mind, such indulgence
 is a disease, and, if not studiously watched
 and opposed, will  easily become a habit.
 In  the studious and active mind, it is a
 wholesome relaxation: the  sensory, in the
 correct language of the poet, "sleeps and
 is refreshed," grows fertile  beneath  the
 salutary fallow, and prepares itself for new
 harvests.
   This is more particularly the case where,
 in conjunction with an attention "screwed
 up to the sticking place," and long con-
 tinued there, a spirit of ardent emulation
 is at the same time stirring, and distracted
 between the hope and  fear of gaining or
 losing  a distinguished  honour or  reward.
 I have seen this repeatedly in young men
 who have  been striving night and day, and
 week after week, for the first prizes of our
 English universities; some of whom have
 indeed succeeded, but with a hectic  ex-
 haustion that has been recovered from with
 great difiiculty; while others, in  the full
 prospect of success, have been compelled
 to relinquish the pursuit and to degrade.
  Yet even without this conflict of feeling,
 where  the attention alone has been too
 long directed to  one or to a variety of
recondite subjects, without relaxation, the
mind suffers considerably, and its powers 
APHELXIA.—APHTHAE.
191
become shaken and confused; of which we
have an  interesting example in the case
of Mr. Spalding, a scholar of considerable
eminence in Germany, as drawn by him-
self, and  communicated  to the  editors of
the Psychological Magazine. (Crichton's
Inquiry into Mental Derangement, 1.237.)
His attention, he tells us, had been  long
kept upon the stretch, and  had  been still
more distracted by being continually shift-
ed from one subject to another, when, being
called  upon to write a receipt for money
paid him on account of the poor, as soon as
he  had written the two firet words,  he
found himself incapable  of proceeding far-
ther.  He strove all he could, and strained
his attention to the utmost, but to no pur-
pose : he knew the characters he continued
to make were not those he wished to write,
but could not discover where the  fault lay.
He  then  desisted, and  partly by broken
words and syllables, and partly by gestures,
made the person who waited for the receipt
understand that he should leave him.  For
about half an hour, a tumultuary disorder
reigned in his senses, so that  he was in-
capable of remarking any thing  very par-
ticular, except that one series of ideas of a
trifling nature, and confusedly intermixed,
forced themselves involuntarily on his
mind.   At the  same time his  external
senses continued perfect, and he saw and
knew every thing around him. His speech,
however, failed in the same manner as his
power of writing, and he perceived that he
spoke other words than those he  intended.
In  less than an hour he recovered himself
from this confusion, and  felt nothing but a
slight  head-ache.  On examining the re-
ceipt on which the aberration first betrayed
itself, he found that, instead of the words
" fifty dollars, being one half year's  rate,"
he had written " fifty dollars, through the
salvation of Bra—;" the last word  being
left unfinished, and without his having the
least recollection of what it was intended
to be.                           I. H.
   APHONIA.  (From a priv., and ^uvr,
the voice.)  More or less complete loss of
voice.  Aphonia ought not to be con found ed
with dumbness (mutitas), as has often been
done.  The former consists in an inability
to produce, the latter to articulate sounds.
In  the former, generally, the voice is not
completely extinct but the patient is able
to speak in a low voice or whisper; whilst
in the latter, there exists the power of ut-
tering loud  sounds, without however, the
faculty of pronouncing syllables or words.
  The production of the voice is the office
of  a complex  apparatus, and ite extinc-
tion results from  most  of the lesions of
this apparatus.   Aphonia is consequently
not a disease, but a symptom—the expres-
sion  of a pathological condition of some of
the organs of phonation.
  The causes of aphonia are very numer-
ous and diversified; the organs which form
the voice  being  subject to many primary
diseases, as well  as liable to be sympatheti-
cally affected,  by the  derangements of
several other organs with which they hold
close sympathetic relations. It would not
be possible,  however, to discuss with  any
practical  advantage,  the  causes of  this
symptom, its indications, and the means of
relieving it, separately from the anatomical
consideration of the organs of voice, and of
the various pathological conditions which
affect  their   functions;  the whole  will,
therefore, be exposed together in the arti-
cle Voice, to which the reader is referred.
                                I. H.
  APHRODISIACS. (From wpeoortq,Ve-
nus.)  Remedies which  have the power of
increasing the venereal faculty, or of re-
viving it when extinct.   The articles for-
merly  supposed  to be endowed with this
virtue, are the tonics, aromatics, odorifer-
ous  gums, balsams,  resins, essential  and
volatile oils, musk, phosphorus, and can-
tharides;  all of which, with the exception
perhaps of the last, are general stimulants,
and  have no direct and specific stimulant
action  on the genital organs.  The can-
tharides, when administered in large doses,
are well known to produce a violent irri-
tation of the urinary organs, followed by
priapism.  But .this  is a disease, and not
the normal condition or exercise of a func-
tion  ; and it is not very probable that coi-
tion, under the  impulse of this irritation,
would be productive of enjoyment, or likely
to increase   population.  There appears,
then, to be no real aphrodisiac; and modern
systematic writers  have very justly dis-
carded such a  class.  The means  of in-
vigorating the  powers  of  the sensual or-
gans are of a general character, and will
be exposed in the article on Impotence.
                                I. H.
   APHTHAE.   (From a*r<o, I inflame.)
Aphtha, Lat.; Aphthe, Apte, Muguet, Ca-
tarrhe buccal, Fr.; Thrush, Sprue, Infant''s
sore mouth,  Eng. An inflammation of the
mucous membrane, with elevation  of the
epithelium,  in  round, oval or irregular,
whitish or ash-coloured vesicles; the con-
tained fluid of which  is said to be separated
into two parts: one albuminous, forming the
rudiment of the new epidermis,—the other
serous, which escapes while the old epi-
dermis is cast in the form of 6curf or scab.
(Craigie.  Elements of Gen. and Path. 
192                         APHTILE.  (Causes.)
Anat. p. 672.)  It affects, most commonly,
the inner surface of the  lips and cheeks,
the gums, roof of the mouth, tongue and
its frenum, and the posterior fauces; less
frequently, the oesophagus,  trachea, and
verge of the anus.   It seldom or never in-
vades the schneiderian membrane; at least
we have never witnessed an instance of its
occurrence there; and both Callisen and
Bateman admit the exemption of this part
from the disease. It still remains an unset-
tled point among pathologists, whether or
not aphtha? ever form in  the stomach and
intestinal tube;  some declaring they do,
while others deny it. We cannot venture,
with safety, to appeal to our  own expe-
rience,  as regards  this question, for our
testimony would amount only to this nega-
tive,—that we have never  seen them in
the parts in question, nor have many other
practitioners of high authority.  But, on
the other hand, several anatomists of un-
questionable character have declared that
they have met with aphthae in the mucous
membrane of the stomach and bowels. It
may however be  asserted,  that they are
most characteristically developed in the
mucous membrane  in which the epithe-
lium is most apparent.
  Authors, especially those of olden times,
have been very liberal in the  application
of the  term aphthae, and  have comprised
under  it many affections of  the mouth
which bear not the slightest  analogy with
this complaint
  In the present article we  shall not in-
quire into the propriety of the distinctions
which have been made between the various
diseases of the mouth—this will more pro-
perly be discussed elsewhere  (see Stomati-
tis); but shall confine ourselves to the
consideration of the affection to which the
term aphtha? really belongs.
  This  complaint has attracted much at-
tention  from modern pathologists,  who,
though they have agreed  as  to the tissue
it invades, differ respecting the particular
portion of this tissue which is its  seat.  It
is admitted that aphthous inflammation is
located  in the mucous membrane; but this
is a complex tissue, and it is not decided,
to  this  moment, which portion of it con-
stitutes the  particular seat of aphtha?.
Neither Gardien, Duges, Guersent, nor
any other writer whom we have consulted,
has attempted to determine a point which
Bichat himself left  undecided; for he
inquires: "Les aphthes  sont-ils aux pa-
pules'?  Siegent  ils  dans   les glandes?
Sont ils une  inflammation  isolee de ces
glandes, tandisque les catarrhes sont char-
acterises par une inflammation generale
d'une etendue assez considerable du sys-
teme muqueux 7"  Billard, however, un-
dertakes the explanation, and declares the
seat of aphthae to be in the muciperous
glands of the mucous membrane,  fie ad-
duces  many  reasons  for his  belief, and
with apparent truth; and names one cir-
cumstance which gives a strong probability
to the propriety of his location; which,  if
true, (for we have not had an opportunity
to test its accuracy), would seem to settle
the question.   He says, " the muciperous
glands of the mucous membrane of the
mouth are  invisible in their natural and
healthy  condition,  being hidden in the
substance of the  membrane, and by their
number make up for the smallness of their
size.   When they become inflamed, they
tumefy, show themselves in the form of
small white spots, sometimes a little colour-
ed in their centres, somewhat elevated, and
frequently surrounded by a slight inflam-
matory  circle.  Occasionally these  small
elevations can be felt by the finger before
they become visible to the eye."  If this
be  found true by future observations,  it
will place the seat of the  aphthous inflam-
mation  in the muciperous glands of the
mucous membrane of the mouth, &c.
   Though emphatically called the baby's
sore mouth, this  affection is not confined
exclusively to very young children, but
often occurs  in  adults  labouring under
wasting discharges, or lymphatic engorge-
ments.  It  may  be said, however, with
much certainty, we think, that aphtha?, as
an essential disease, is confined to infancy
and childhood; but it may  also exist in
them as a symptomatic affection; for chil-
dren, as well as adults, are liable to wast-
ing and chronic diseases.  Bateman seems
to think that aphtha? may primarily occupy
the stomach, and  then travel up the oeso-
phagus to the pharynx; a circumstance, in
our estimation, of very doubtful character,
and  not very susceptible of proof; for the
symptoms which he says accompany this
location of the disease, and mark ite pro-
gress, from its original seat to the mouth,
(as anxiety and oppression about the precor-
dial are too common, as well as too vague,
to establish either the origin, or the seat
of this affection.
   Causes. The remote and exciting causes
of aphtha? are numerous, highly influential,
widely  spread, and constantly  operating.
Among the most prominent is the foul air
produced by many bodies being crowded
together, as  in hospitals  and asylums for
children, where both the sick and well in-
habit the same apartments, and breathe the
same atmosphere.  Dark and  cavernous 
APHTHAE.  (Symptoms.)                         193
dwellings, an ill-prepared and innutritious
state of the mother's or nurse's milk, and
a feeble constitution, especially from im-
perfect development or premature  delive-
ry, are productive of aphthae, generally of
the worst character.  To these causes may
be added, food of an unsuitable quality, as
well as quantity; ascescent milk, or other
substances about  to ferment from long
standing, or  from  too much sweetening;
a  want of cleanliness; too great a con-
finement to  the bed, or cradle, &c.  But
there is no one cause of idiopathic  aphtha?
that is so frequent and so certain as the
want of the mother's milk, soon after birth.
It too  often  happens,  from a variety of
causes, that the secretion of milk does not
take place early enough, or continue with
sufficient certainty, for the necessities of
the child.  The mother may be ill before
labour, or immediately after; the  nipples
may be badly formed  or  sore; abscesses
may form, and  prove  destructive of the
organization of the mamma?, &c.   From
either of these causes the child  is de-
prived  of  its  natural   nourishment;  in
consequence of which, instead of being
supplied immediately with  a  fresh breast
of milk, it  is forced to  swallow an unna-
tural  and  ill-prepared  substitute;  and
which thus becomes one of the most pow-
erful causes of aphtha?.
   The exciting causes are nearly the same
as the predisposing.  They are whatever
stimulates, either  mechanically or chemi-
cally,  the  tender  mucous  membrane, as
food, acid from fermentation; or unsuitable
to the age  of the child, as animal sub-
stances, to very young subjects, food given
too hot, or too tenacious for the power of
the stomach; mechanical injury, from rude
attempts to clean  the mouth; or this per-
formed with an  improper material, as flan-
nel or coarse  muslin, under the pretence
of keeping the mouth  clean.  This kind
of discipline is  a  more fruitful  source of
the disease than  is commonly supposed,
and therefore it should be carefully avoid-
ed.  The  removal of  the recrements of
food from the mouth is a very proper opera-
tion ; but it should be managed by a tender
and careful hand, with a piece of very fine
linen,  and with simple water only.   We
are of opinion, that many children would
escape the painful, and sometimes danger-
ous affection  in question, were they not
subjected to this  rude  manoeuvre.
   Symptoms.  This affection has  its pre-
monitory symptoms, but not always in a
very obvious degree.   The child is gene-
rally more thirsty than usual, manifested
by the greatness with which it takes the
   vol. 11.          17
breast, and  this is observable even at  a
very early age; the lips  are sometimes,
for several days, more than naturally red;
so also the tongue and gums.   This con-
dition of redness is natural, however, to
all  very young  children,  and  must not,
therefore, be  looked  upon  always, as  a
morbid condition of those parts.  The child
also becomes fretful, and often even cries
as if it were in pain; and this before the ap-
pearance of the eruption. It is likewise dis-
posed to sleep more than its natural wont
as well as more profoundly.  Fever some-
times precedes, but not necessarily;  and
this state of the circulatory system is de-
tected more by the thirst of the child, and
its  breathing, than by the pulse; for the
pulse, in very young children, is not easily
detected, and if found, not easily counted.
Indeed, according to Billard, there  is
more uncertainty in the number of pulsa-
tions of the arteries in a given  time, than
is usually supposed.
  After  a continuance,  for a  longer or
shorter time, of the premonitory symptoms,
if they exist, transparent vesicles, of a light
grayish colour, may be observed to show
themselves  upon  one  or  several  places,
within the mouth and lips.  These vesicles
are surrounded at their bases by small in-
flamed circles, which are  a little thicken-
ed, or elevated, almost as  in scarlatina .or
measles, above the surface of the mucous
membrane.  These harden as they develop
themselves, and  thus give rise  to the
vesicular form of the  eruption.  This ve-
sicular character increases until the second
or third day: the vesicles  then open spon-
taneously, and give issue to a  whitish or
pearl-coloured fluid, leaving behind an ul-
cerous appearance.  This change  in the
aspect of the vesicles is attended by more
or less pain, as  is manifested by the un-
willingness of the child to take  the breast,
and its apparently suffering inconvenience
in  its attempts  to extract  the milk.   It
often lets the nipple  slip from its mouth,
which it seizes again with  apprehension.
  The period of this ulcerous condition  is
of  uncertain  duration; but it generally
occupies from three  or  four days, to as
many weeks,  according as the recupera-
tive powers of the system may be more or
less favourable ; to the force and  contin-
uance  of the remote causes, and as the
mode of treatment may be more  or less
appropriate.  The ulcerations, during this
period, if the  parts are not healthily dis-
posed,  rather  increase in size  for some
time; but after a while the bases of these
little pits become  slightly red,  and show
a disposition to cicatrize.  Their size gra- 
194                        APHTILf*.  (Symptoms.)
 dually diminishes, and they  sink to the
 level of the membrane beneath.
   The progress of healing, after it  com-
 mences, is pretty  rapid hi general, unless
 some cause of retardment  should super-
 vene, to renew the aphthous inflammation;
 as an improper plan  of treatment,  or a
 renewal or multiplication  of the  remote
 causes, which sometimes happens: hence
 the succession of crops of the aphthous
 efflorescence.  These  exfoliations are  re-
 newed sometimes, without our being able
 to assign the cause.   But, under the best
 circumstances, it requires only two or three
 days for the stratum of hardened lymph
 to be thrown off, by a kind of exfoliation.
 After  this is successfully performed, the
 epithelium beneath betrays no signs of the
 previous ulceration, except that it remains
 for  some time  more  red  than natural.
 This form of aphtha? is called, by several
 of the French writers, " discrete aphthae,"
 and is the mildest, and, under favourable
 circumstances to  the  patient the  most
 common.  The disease, in this form, will
 run its course in from one to three or four
 days, and rarely disturbs the  functions of
 the system; and the child is soon restored
 to its usual health.
   In contradistinction  to these mild aph-
 tha?,  a severer condition  is sometimes
 formed, especially in very young and fee-
 ble children;  and particularly when not
 in possession of a healthy breast of milk,
 or other  suitable  nourishment  Children
 worn down by previous illness of any sort
 are liable to severe and sometimes  dan-
 gerous aphtha?; which is, however, nothing
 more than an exalted pathological condi-
 tion of the mucous follicles of the part or
 parts involved in the inflammation.
   To make different species of aphthae,
 when these distinctions are derived merely
 from the portion of the mouth the efflores-
 cence may chance to occupy, or from the
 forms the patches  of aphtha? may assume,
 is surely unnecessary,  if not embarrass-
 ing  and hurtful.  For in  all the modi-
 fications of this disease,  the symptoms,
 the tissue, the progress, the exfoliation?,
 the appearance of  the tissue beneath, the
 process of cicatrization or  deterioration,
 are the  same, differing only in degree.
 This rage  for making  species has been
 carried to such extent by some, as to cause
 a difference in name for the disease, as it
 may be situated upon the tip or back  part
 of the  tongue, and even according to the
 thickness of the  respective mucous coat-
 ings ; nay, the size of the pustules, on this
organ,  has  been claimed as a ground of
distinction.  But  can  any therapeutical
 advantage be derived from this attempt to
 establish varieties of aphthae  from these
 circumstances 1  We might as well create
 new names  for  the  different  sizes of
 phlegmon, or for the different degrees of
 intensity in the paroxysms of an intermit.
 tent, or for the different degrees of inflam-
 mation in ophthalmia.   Did the severity
 or mildness of aphtha? depend upon their
 occupying distinct tissues, it might then
 be important to ascertain to  which tissue
 each form belonged, and they then would
 be entitled to specific names.   But as the
 mild and malignant forms of aphtha? oc-
 cupy the same organization, there can be
 no propriety in designating them but from
 the  respective  degrees  of  inflammation.
 That their phenomena will be somewhat
 different we will  freely admit; but even
 these will depend more upon the intensity
 than upon any specific difference in the
 inflammation or variety of tissue they may
 occupy.
   The most remarkable differences, in the
 several stages of this affection, are the
 number of the mucous follicles that may
 be involved by this peculiar modification
 of inflammation.   In one form only a very
 few  may be implicated, as in the mildest
 form;  in a  severer form, very many may
 be involved.   Yet in these  instances the
 vesicles  undergo  the self-same  changes
 during their progress, though this differ-
 ence in  appearance may exist   In the
 first instance, the vesicles are too few to
 coalesce   and  form  a  continuous crust;
 whereas, in the other, their number being
 great,  they will pour out  their  contents
 much more abundantly, and  form an ex-
 tensive crust,  which being  cast off, an-
 other and another may form, as the remote
 cause continues to act or as the inflam-
 mation may continue  to exist, or as the
 treatment may have been appropriate or
 otherwise.
   In a more aggravated form, as in the
 confluent, or, els some have termed it, the
 " stationary," the symptoms are more se-
 rious and tormenting, and  the  child  is
 evidently a much greater sufferer.   The
 throat becomes affected, and a great diffi-
 culty is  experienced in swallowing,  in
 consequence of the  posterior fauces and
 pharynx  being much loaded by the erup-
 tion.  The  child, in this  stage of the
disease, is importunate for drink, but de-
liberates  about receiving it when it is pre-
sented, from the suffering it  experiences
on every attempt to swallow; and the pa-
tient will oftentimes reject it, rather than
encounter the pain.   We once saw a case
of this kind, where the child would permit 
                           APHTH/E.

nothing to be put  into its mouth, and ab-
solutely died from inanition.  Upon ex-
amining it after death, the oesophagus, as
far as the cardia, was literally blocked up
with aphthous incrustations.   But the ef-
florescence stopped at the cardia, nor was
there a trace of the disease in either the
stomach or bowels, though the verge of
the anus was covered with this eruption;
which, most probably, was caused or called
into action by the frequent discharge of
an acrid and greenish-looking fluid.
  This stage or form of aphtha? is almost
always sure to be  attended  by frequent
vomitings of porracious matter; great anx-
iety about the precordia; rapid, and  if it
continue long enough, extreme emacia-
tion, from profuse and harassing diarrhoea;
and under certain circumstances, as in
crowded   hospitals, &c,  a  consuming
fever,  of a low grade, is  almost sure to
ensue, and hasten on the disease to a fatal
issue.
  Non-Contagiousness.  This disease  is
looked upon by some as contagious, but of
this we have the strongest doubts; though
it is pretty generally admitted to be occa-
sionally epidemic.  The proof offered of
its  being  a contagious disease  is every
way insufficient;  namely,  its excoriating
the nipples of the mother.  First, because
we have  seen  the  nipples remain unin-
jured, though the child may have had the
disease in an exalted form; secondly, be-
cause  sore or excoriated nipples are very
common, where there is no aphthous mouth
to  produce  them; and thirdly, we have
known an aphthous child to be kissed fre-
quently by other children, without the dis-
ease communicating itself.
  Prognosis.  Our prognosis must be go-
verned by several circumstances, each of
which will have a strong bearing on this
point.  As a general rule, the younger the
subject the greater the risk,  even if the
aphtha? be of a mild form; as the recupe-
rative powers of the system  are weak in
such cases. The risk is increased, if, added
to this early age, the system be weak from
imperfect development, or rendered so by
previous suffering; and especially if, added
to this, the patient be  subjected to the ac-
tion of bad air, bad milk,  improper diet,
constant want of cleanliness, &c.
  If the  aphthous  efflorescence spreads
rapidly, and becomes of a dark colour,
without exfoliating, and invades the whole
of the fauces, tongue, and oesophagus, to
such an extent as to render it difficult for
the child to take a proper share of the most
suitable nourishment; or should frequent
(Prognosis.)                        195

 dejections  take place  of a thin offensive
 greenish water,  or should the  stomach
 revolt, and puking ensue ; and if fever be
 added to these, the case may be looked
 upon as nearly  hopeless under the cir-
 cumstances of age and constitution just
 named; but an older child, with a better
 constitution, and  proper nourishment  at
 command,  may struggle through the dis-
 ease, unless it be symptomatic;  then the
 inferences must be drawn rather from the
 state of the symptomatic  disease, than
 from the  condition of the aphtha?  itself;
 remembering,  in forming an  opinion of
 the disease, that its danger is always aug-
 mented by the presence of aphtha?.  This
 may be said of aphtha?  at any period of
 life, or under  any circumstances of free
 ventilation, proper nourishment, and treat-
 ment ; therefore, the sympathetic, or sys-
 tematic, is always (caderis paribus) more
 dangerous than the idiopathic form.
   Should  aphtha? be attended with fever
 as one of  its symptoms, it will denote in-
 creased danger, as it will show that the
 system sympathizes with the  local affec-
 tion; for  we have said that  fever, espe-
 cially an exalted degree of it is not an
 essential  character of aphthae.
   On the other hand, when aphtha? is idio-
 pathic ; the eruption not erratic; the con-
 stitution good;  the air pure;  the nursing
 and food appropriate, the disease is of easy
 management  and  under  such circum-
 stances  rarely becomes alarming, and
 many times scarcely  inconvenient  But
 even under these favourable circumstances,
 the disease  may by mismanagement be-
 come alarming, though the efflorescence
 may be sufficiently limited;  the danger
 not being always  commensurate with its
 extent.  For we have  seen very alarming
 symptoms  succeed to this apparently mild
 and safe form, without being  able  to say
 by what agency the change has been pro-
 duced.  When this happens, the child be-
 comes  fretful  and  drowsy;  the bowels
 yield, and diarrhoea occurs; the exfoliations
 from the  mouth take  place in detached
 spots, leaving the epithelium very tender,
 dark coloured, and disposed to bleed on very
 slight injury.  Fever is augmented, thirst
 increased,  swallowing becomes  difficult,
 the secretions of the mouth are arrested,
 and the tender epithelium, especially on
 the lips, cracks, and remains so  for some
 time.  This condition  prevents the child
 from closing its mouth sufficiently tight to
 extract the milk from the  breast, and it
 thus suffers from  want of nourishment.
 This painful and threatening condition may 
196                        APHTH/t,.  {Treatment.)
however, be frequently subdued by proper
management and appropriate treatment.
   Treatment.  In  treating this  disease,
except perhaps in its very mildest forms,
much care is required, both as regards lo-
cal and general management; otherwise
a mild grade may be changed into one of
danger and severity. The first care should
be, to abstract the remote cause or causes,
as far as this is practicable.  An impure
should be exchanged for a pure air,  and
an  innutritious or  impure milk should
give place to milk  of opposite qualities;
cleanliness must be substituted tor filth;
food,  of quality and in quantity  adapted
to the age and constitution of the child,
and force of the disease, must be furnished.
  The cruel and preposterous practice of
scrubbing the mouth,  under the pretext
of its being an  essential step in the cure,
must be prohibited in such a manner as to
prevent its repetition.  This practice is
one of the many vulgar errors connected
with the management  of children, which
every endeavour must be made to correct.
It has taken  its rise from the notion that
the mouths of all young children are filthy,
and that this condition is the cause of aph-
tha? ;  and as the coarseness of the mate-
rial,  and  the force  of the hand that em-
ploys it, will necessarily remove the white
aphthous crust, it is vulgarly believed that
they remove the disease.  Under this de-
lusion, the plan is persevered in, though
every repetition shows the  parts to be co-
vered by a new crop of aphthae, and  this
even to a greater degree.   This new pro-
duct excites no doubts of the propriety of
the course, but rather, on the contrary, in-
duces a perseverance in it  with increased
energy and additional force  of hand.  Some
stimulating substance, as honey, molasses
or soap, is even added to the piece of
rough flannel; and this plan is  pursued
with  such cruel industry, that blood is al-
most sure to follow  the violence.  In  this
manner, the simple forms  of aphtha? are
converted into those  of  much  greater
severity,  as well  as  danger.  For  the
maintenance of cleanliness, it  is  only
necessary to have the mouth gently wash-
ed with cold water and a piece of fine  rag,
once a  day, and this  especially in  the
morning.
   In the commencement  of aphtha?, if
preceded by erythema,  the mouth should
not be  touched, even by  cold water, as
every increase of irritation, however small,
augments the  mischief: the only topical
application we permit in this state of the
disease, is the very frequent use of a pretty
rich  infusion of the  slippery-elm  bark
( Ulmus fulva).  This, in small quantities,
is  to be poured into the mouth, very fre-
quently, which relieves the painful irrita-
tion almost immediately.  This should be
continued, until the inflammation subsides,
which it  generally does  as soon as the
aphthae appear, or until they so much abate
that there may be  no apprehension from
the use of a gentle stimulant.  The best
for this, in our estimation, is the borate of
soda and loaf-sugar, in equal quantities, or
with a lesser proportion of the borax if
the inflammation persevere.   These arti-
cles are to be very finely pulverized, and
of this powder  a  small  pinch is  to  be
thrown dry, into the mouth, three times a
day, and  permitted to spread itself over
the tongue and  mouth  by its solution in
the saliva.  We are  aware that Dr. Un-
derwood and some others have no confi-
dence  in  any local application;  and the
French writers in general oppose the em-
ployment  of the borax; but our own ex-
perience in this plan, justifies the use of
this article, we think, most fully; it  rarely
indeed disappoints us.   It is true, it may
be used too  strong, or  too frequently for
the immediate condition  of the mouth;
this  should  be carefully guarded against,
by a careful  examination  of the  state  of
the disease, and  the quantity of the borax
regulated by the less or greater intensity
of the inflammation.
   The crust, or white efflorescence, is re-
moved very quickly by the application of
the borax and sugar; but if the inflamma-
tion continue, a fresh secretion takes place.
A  few applications of this  remedy, how-
ever, will very soon abate the inflamma-
tion ; and after the crust  is removed, the
surface of the  epithelium  becomes less
and less red, if everything goes on right
But if we find that instead of the reforma-
tion of the white  crust, the epithelium is
left  very  red and smooth, and the parts
very sensible to the  touch  or to the mo-
tions of the  tongue and jaws, the borax
must be suspended and the slippery-elm
tea substituted,  until these appearances
abate or are removed.   We  have  found,
under this state of things, the Armenian or
red bole,  mixed in  equal proportions with
sugar, very serviceable; or if the epithelium
yield and break into chaps,  or should the
gums and the inside of  the cheeks  be dis-
posed to ulcerate, the decoction of bark is
the best and indeed a most certain remedy.
Half an ounce of the powdered bark is to
be simmered for fifteen minutes in half  a
pint of boiling water; it is then to be al-
lowed to settle, and a little of it thrown
into the  mouth, five or six times a day. 
APHTHJE.—APIUM.                          197
During  the use of these  remedies,  we
never permit the mouth to be washed, as
this  is sure to  interrupt  the  process  of
cicatrization;  unless  there should be a
tendency to slough ; in this case, the parts
so circumstanced may be freely swabbed
with the infusion, or even the  dry pow-
dered bark may be used.
  The general treatment  of aphtha? must
depend upon the condition of the  system
at large. If fever attend, an antiphlogistic
plan must be adopted; if debility be con-
siderable, a nutritious or  even sometimes
a cordial treatment may be necessary.  As
diarrhoea is almost certain to precede or
accompany aphtha?,  remedies suitable to
its nature and extent should be employed.
When the stools are green or become so
after standing, but not watery, magnesia
in small and repeated doses will be found
the best remedy; if yellow, and they are
passed with pain or straining, a tea-spoon-
ful,  or  more, according to the  age  and
habits of the child, of castor oil,  with a
drop of laudanum, will be  required.   If
the diarrhoea be  importunate; the stools
watery and green; or  if mixed  with the
mucus of the bowels, the chalk mixture,
with the free use of gum Arabic water,
will be necessary.   The  oil of butter is
highly useful in this state  of the bowels.
This is  made  by pouring  boiling water
upon a lump of butter; and when melted,
a  tea-spoonful  is to  be skimmed off,  and
given five or six times a day.
   If the child  suffer much from pain, the
occasional use  of laudanum, especially in
form of enemata of rich flaxseed tea,  will
be proper.  In this state of the mouth and
bowels, very minute doses of calomel and
chalk have been  highly  recommended.
The anus  is almost sure to be much  irri-
tated and inflamed, as well as the adjacent
parts; constant attention should therefore
be paid to them. They should be kept  per-
fectly clean, by carefully  washing them
with warm rich flaxseed tea, and then co-
vering the parts affected with a thin coat
of fresh hogs' lard or simple cerate. A piece
of what is called the oiled silk, such as is
employed for hat covers, would be highly
useful to prevent the contact of the diaper
or clothes.  The same diaper should never
be used twice,  without washing it.
   In symptomatic aphthae, the same local
applications may be used; but nothing be-
yond temporary comfort must be expected,
as the  extent  and severity will  depend
upon the disease which it accompanies;
and for the treatment of this we must re-
fer to the appropriate articles.
                    Wm. P. Dewees.
                  17*
  APIUM. (Botany and Materia Medica.)
  Sex. Syst.  Pentandria Digynia.—Nat.
Ord. Umbelliferae.
  Gen. Ch. Fruit ovate, striated.   Invo-
lucre one-leafed.  Petals equal.  Willd.
  1. A. graveolens.—Celery.—Ache,  Ci-
leri, Fr.;   Eppig,  Sellerie, Germ.—Sp.
Ch. " Cauline leaves cuneiform." Willd.
Sp. Plant.—Celery  is a  biennial  plant,
with a spindle-shaped root, and an  erect,
furrowed, branching stem, rising from one
to four feet  in  height.  The leaves are
smooth, shining, and of a  dark green co-
lour.   Those which spring from the root
are pinnate,  with long,  channeled, em-
bracing footstalks,  and roundish, three-
lobed, incised-dentate leaflets. The cauline
leaves are ternate, with leaflets which are
wedge-shaped and three-parted,  or entire
and lanceolate.   The  flowers are small,
whitish, and disposed  in terminal and la-
teral umbels, which  are either sessile or
supported upon  short footstalks, and  are
destitute of involucre, or have  in the place
of it a three-parted leaf. The fruit is simi-
lar to that of the species next described,
but somewhat smaller.
   Celery  is a native of Europe, growing
throughout that continent in ditches  and
wet places, particularly on the borders of
salt streams, and near the sea-shore.  It
is extensively cultivated  both in Europe
and this country, for domestic use.  All
parts of the  wild plant have  a  disagree-
able odour, and a sharp bitter taste. These
properties depend upon the presence of a
peculiar volatile oil, and are lost or dimin-
ished by drying.  The plant was employed
as a medicine by the ancients, and is  still
retained in many of the  Pharmacopoeias
of continental Europe.  The  root, herb,
and seeds (Radix, Herba,  et Semen Apii)
are designated as officinal.  The root ap-
pears to have been most used.   It  is diu-
retic ;  but is said also to be capable of pro-
ducing deleterious  effects upon the sys-
tem,  and is  accused by  some of having
poisonous  narcotic  properties.  Neither
this nor any  other part of the plant is at
present much used as a  medicine.   The
root was one of the  radices quinque ape-
rientes majores, and the fruit one of the
semina quator  callida minora, of older
Pharmacy.
   The effect of cultivation upon this plant
is remarkable.   It  loses  its disagreeable
odour  and taste,  and its  deleterious pro-
perties, and becomes an edible vegetable
of an  exceedingly  pleasant flavour.  In
the leafstalks and roots a degree of sweet-
ness is developed;  and the presence of
mannite has  been demonstrated in  these 
193                                 APIUM.
parts by Vooel. The leaves are employed
as a condiment in soups; and the leaf-
stalks, blanched  by covering them with
earth during the growth of the plant, are
white, tender, and juicy,  and in great es-
timation as a salad.  The root  of the or-
dinary garden celery is not without diu-
retic properties, and, in the  form of infu-
sion,  may be  advantageously used  as an
adjuvant to more powerful  remedies in
dropsical and nephritic affections.
  2.  A. Petroselinum.—Parsley.—Pcr-
sil, Fr.; Petersilie, Germ.—Sp. Ch. " Cau-
line  leaflets linear, involucels  minute."
Willd.  Sp. Plant.—This is a  biennial
plant,  with an erect,  smooth,  striated,
branching  stem,  two  feet  or more  in
height.  The leaves are decompound, with
smooth, light-green, deeply  incised leaf-
lets, the lobes of which are linear-lanceo-
late  and acute.  The radical and  lower
cauline leaves are on long channeled foot-
stalks;  those  on  the upper part of the
stem  are less compound, and on shorter
footstalks;  the uppermost are simply ter-
nate.   The  flowers are small, yellow, and
disposed in compound  terminal  umbels,
with  a  one-leafed general involucre, and
partial involucres composed of six or eight
awl-shaped leaflets.  The petals  are five,
equal, roundish,  and pointed, with  their
summits inflected.  The fruit is roundish-
ovate, somewhat compressed, and ribbed;
and consists of two portions usually  called
seeds, connected by their flat  surfaces, and
separating when perfectly ripe.
  Parsley is a native of Sardinia, Sicily,
and Greece, and  is now everywhere cul-
tivated in gardens, chiefly for the sake of
its leaves, which are much used as a con-
diment in culinary preparations. Its flow-
ers appear  in June, July,  and  August.
There are  several varieties of the  plant,
differing in the shape of the leaflets, which
are in one very narrow, in another broader,
and  in  a third wavy.   The  whole plant
has a peculiar aromatic  odour, dependent
on a  volatile  oil,  which  is  separable by
distillation.   By our national Pharmaco-
poeia the root only is recognized; but the
herb and fruit possess similar properties,
and  are directed by numerous  medical
codes on the continent of Europe.
  The  root  (Petroselinum, Ph. U. S.)
is spindle-shaped, sometimes branching,
about as thick as the finger,  and  a foot or
more  in  length.   Its  upper  portion  is
marked by  close  annular wrinkles, the
lower is smooth.   Externally it is yellow-
ish white,  internally,  fleshy and white,
with a central yellow portion. Its taste  is
sweetish, aromatic, and  pungent.  Besides
 volatile  oil, it contains sacciiarine  and
 mucilaginous  principles.  By drying,  it
 shrinks, becomes wrinkled and of a light
 yellowish-gray colour, and loses much of
 its odour and taste, which are entirely de-
 stroyed by time.
   The seeds  (Petroselini Semina)  are
 small, not  more  than a line in  length,
 ovate, flat on  one side, about as thick as
 they are broad, somewhat curved inwards,
 with  five  prominent  longitudinal ribs
 which are yellowish, while  the intervals
 are of a dark greenish colour.   They pos-
 sess strongly the aromatic odour and taste
 of the plant, are somewhat bitter,  and re-
 tain their sensible properties for a long
 time after drying.
   The volatile oil may be obtained most
 conveniently from the seeds, of which one
 pound is said to yield from two to  two and
 a half drachms.  It is ofa pale yellow co-
 lour, has the odour and taste of the plant,
 and upon  standing deposits a white solid
 substance, which crystallizes in  needles.
   Therapeutic properties and uses. Pars-
 ley was known to the ancients as  a medi-
 cine, and  is still occasionally  employed,
 though no great reliance is  placed upon
 its virtues, and it is probably more used in
 domestic than in regular  practice.  Its
 properties are  those of a gentle carmina-
tive diuretic,  usually agreeable  to  the
 palate, and  acceptable to the stomach.
 The complaint in which it  is most  es-
 teemed  is  dropsy,  in the treatment  of
 which it is sometimes advantageously as-
 sociated with  other diuretics. "The root,
 which is the part usually preferred for this
 purpose, is said  occasionally to act with
 considerable energy.  Dr. Chapman speaks
 of it in highly favourable terms.   In his
 treatise  upon  Therapeutics and  Materia
 Medica  (I. 276.), he states that  he  has
 known it to cure ascites, after tapping had
 been twice resorted to.   It is also useful
 in suppression of urine, the painful urina-
 tion of nephritis, and  in strangury from
 blisters; and  has enjoyed  the credit  of
 possessing  lithontriptic properties. The
 best form  of administration is that of a
 strong infusion, which should be used very
 freely.   Decoction is injurious, at least if
 long continued, by driving off the volatile
 oil.  Dr. Cullen  states that he has often
 tried the  decoction, and not found it to
 produce any diuretic effect. The infusion,
 if taken warm, and if the patient be at
 the same time  warmly covered, some-
 times determines to  the skin,  and  has
 therefore been employed to  promote  the
 eruption in exanthematous diseases.
   The seeds have been used as a carmina- 
APNEA.—APOCYNUM.
199
 tive,  and for  the  same  purposes  as  the
 root i° dropsical, nephritic, and calculous
 affections; but are at present seldom pre-
 scribed.  Their dose is from ten to  twenty
 grains in powder,  and a drachm in infu-
 sion.   It is asserted that, sprinkled in the
 state of powder upon the hair,  or  applied
 in the shape of ointment made  with fresh
 butter, they are an effectual and safe re-
 medy  in cases  of vermin infesting  the
 head.  (Richter.  Arzneimittellehre.  II.
 465.)
   The volatile oil, and  the solid  deposit
 from the oil called Parsley camphor, are
 said to possess the properties  of the see^
 in a concentrated state, and to be suscepti-
 ble  of the same practical  applications.
 They are not however, used in the United
 States.
   The fresh herb has been highly  recom-
 mended as an external application to pain-
 ful swellings of the mamma?  and other
 glands, to the stings of insects, and even
 to scirrhous tumours.   It should be boiled
 with milk to the consistence of a poultice,
 and laid on the affected part.
   Some of the Pharmacopoeias of the con-
 tinent of Europe direct a distilled water
 to be prepared from the herb  and seeds,
 which is used for the same purposes as the
 plant  itself, but  is a very feeble prepara-
 tion, and is  unknown in the practice of
 this country.
   Parsley is  an ingredient  in numerous
 diuretic and aperient preparations, which
 have at different times been recommended
 and employed.  The herb, used as food,
 was formerly thought to have the property
 of aggravating  and even producing  epi-
 leptic  fits; but  there is no good  founda-
 tion for  this opinion, which may possibly
 have originated in the fact, that  the JEthu-
 sa Cynapium or Fool's-parsley, a poisonous
 weed  growing in the gardens of Europe,
 and  bearing  a considerable  resemblance
 to the true parsley, has sometimes been
 employed for it by mistake.
                      Geo.  B. Wood.
   APNEA or APNCEA, APNEUSTIA.
 (From a priv. and jtvfw, I respire.)   Sy-
 nonymes of Asphyxia (q. v.).       I. H.
   APOCENOSIS.  (From arto, out, and
 xwuais,  evacuation.)  Cullen  and Swe-
 diaur have applied this term  to  morbid
 fluxes.                           I. H.
  APOCYNUM. (Botany and Mat. Med.)
 Dogs-bane.
  Sex. Syst.  Pentandria Digynia.  Nat.
 Ord. Apocynea?.
  Gep. Ch.  Cat.  very  small,  five-cleft,
persistent.  Corol. campanulate, half five-
cleft, lobes revolute, furnished at the base
with five dentoid glands alternating with
the stamina.  Anth. connivent, sagittate,
cohering to the stigma by  the  middle.
Style obsolete.   Stigma thick and acute.
Foil,  long  and linear.   Seed  comose.
NlTTALL.
   This  genus, in common with all those
composing  the natural  order  to which  it
belongs, is  possessed of active qualities.
All are  acrid,  purgative, and in some in-
stances  very poisonous, arising from the
presence of a white and viscid juice, or
of a peculiar principle.   There are about
twenty  species  of this  genus known to
botanists, of which  but three are natives
of the United States,—these  are the A.
androsamifolium, A. cannabinum, and A.
hypericifolium, to which some authors add
a  fourth, the  A. pubescens,  considered
by others as a variety of A. cannabinum.
The two first  of these are recognized as
officinal in  the  United  States Pharmaco-
poeia.
   1.  A. androsaimifolium. — Dogs-bane.
Sp. Ch. "Leaves ovate, smooth  on both
sides, cymes lateral and terminal, smooth;
tube of the corolla longer than the calyx."
Beck.   This species  is by no means un-
common, growing naturally from Canada
to Georgia.   It is usually found in woods,
hills, dry or sandy soils; rarely met with „
in limestone  districts.   It  is perennial,
herbaceous, generally about four feet high.
The stem  is  smooth  and covered with a
tough and  fibrous bark.  The leaves are
opposite, petiolate, ovate, entire, smooth
on both sides.  The flowers are in cymose
racemes, of a flesh colour. The peduncles
are furnished with  minute  acute bracts.
The fruit is  in the form of a pair of slender,
linear, acute, drooping follicles, containing
numerous,   oblong,  imbricated seeds, at-
tached  to a central receptacle and fur-
nished with a long, downy, pappus.   It is
very lactescent, affording on the slightest
incision a  profuse exudation  of a milky
fluid,  which on drying assumes  the ap-
pearance of caoutchouc.
   The  part used is the root, which is
large, lactescent, and of a disagreeably
bitter taste; the active portion is the bark,
which forms about two-thirds of the  root.
From some experiments of Bigelow, it
appears to  consist of a bitter extractive
principle, a colouring principle soluble in
water but not;  in alcohol, caoutchouc and
volatile  oil.  Its active properties are, how-
ever, soluble in both these menstrua.  Dr.
Zollickoffer obtained  178 grains of al-
coholic  and  2-^ grains of watery  extract
from 3240 grains of the bark.
  This root  possesses emetic  and diapho- 
200                              APOCYNUM.
retic properties.   In doses of from thirty
to forty grains it very  promptly induces
emesis,  occasioning slight previous nau-
sea ; hence it is well calculated for those
cases in which it  is wished  to  evacuate
the  contents  of  the  stomach  merely,
without  producing  that   relaxation  of
the muscular  system, which is incident
to a long-continued  nausea.   As a dia-
phoretic it is much  inferior  to many
other of the vegetable emetics, as it re-
quires  very large doses  in  combination
with opium to produce the desired effect.
Like  ipecacuanha, when  given in small
doses it gently stimulates the  digestive
apparatus, and thus produces a correspond-
ing impression upon the general system.
  2. A.  cannabinum. Indian Hemp. Chan-
vre Indien, Fr.;   Fliegen Fangemdes,
Germ.—Sp. Ch. "Stem upright,  herba-
ceous. Leaves oblong tomentose beneath;
cymes lateral, longer than the leaves."
Loudon.  There  exists considerable dif-
ference of opinion among botanists, whe-
ther the A. pubescens, Brown, is  a spe-
cies or a mere variety of the A. cannabi-
num. They certainly resemble each other
 very closely  i^i  almost  every particular,
 and as their medical properties are iden-
 tical, we have adopted a specific charac-
 ter which whilst it will  include both, will
 at the same time serve to distinguish them
 from the other species of the genus.  The
 Indian Hemp is  a perennial plant, usually
 about two  to three  feet in height, having
 a red or brown  stem,  and oblong ovate,
 somewhat pubescent leaves.  The flowers,
 which are  small and of a greenish-white
 or yellowish-green colour externally, and
 pink internally, are collected in paniculate
 cymes.   This species  is found in most
 parts  of the  United States,  growing  in
 waste lands and neglected situations. The
 root, which is the officinal part, is hori-
 zontal, extending to a  great  distance; it
 is of a reddish-brown colour when young,
 but of a dark chestnut  when old;  when
 wounded it affords  a milky juice, analo-
 gous to that spoken  of above.  In the fresh
 state, it has a nauseous, somewhat acrid
 and permanently bitter taste, and a strong
 and unpleasant  odour.   When  properly
 dried, it is very brittle and is readily pul-
 verized,  affording a powder  resembling
 that of ipecacuanha.  The ligneous por-
 tion of the root  is of a yellowish white,
 having some  odour  and a marked bitter
 taste.   The cortical part is brown exter-
 nally, white within,  of a very bitter, nau-
 seous taste, somewhat resembling that of
 the Sanguinaria Canadensis.  According
 to Drs. Knapp and Griscom, who analyzed
 this root, it contains tannin,  gallic acid,
 gum, resin, wax,  fecula,  colouring matter,
 lignin,  and a  bitter principle for  which
 they both propose the name of Apocynin,
 and on which the activity of the root de-
 pends.
   The Indian hemp acts powerfully on the
 system,  producing emetic, cathartic, diu-
 retic, and sudorific effects. Its first opera-
 tion, in a full dose, is to cause much nau-
 sea, diminishing the frequency of the
 pulse, and occasioning a drowsiness inde-
 pendent of the exhaustion usually conse-
 quent  upon vomiting; this latter is  copi-
 ous, and  is soon  succeeded by large and
 feculent  watery  alvine  evacuations.  A
 general perspiration  almost invariably fol-
 lows its exhibition. Its diuretic properties
 are  not so universally  displayed,  being
 very  manifest in some  cases,  whilst in
 others they do not display themselves in
•the  slightest  degree.  It also acts as a
 sternutatory, exciting much irritation of
 the Schneiderian membrane.   The fresh
juice has  likewise been employed  as a
 lotion  in several cutaneous affections.
   The disease in which  it has been found 
APONEUROSIS.—APOPLEXY.
201
most useful is dropsy, in which, from the
concurrent  testimony of many  eminent
practitioners,  its remedial powers are un-
equivocal,  sometimes acting as a hydra-
gogue,  and at  others causing  the  most
profuse discharges of urine, and thus re-
lieving the tissues  from their morbid bur-
den.  It appears  very analogous  in  its
effects in this disease, to the Madar (As-
clepias gigantea),  so celebrated in  India
in the treatment of dropsical effusions, and
like that plant would perhaps prove useful
in  obstinate  cutaneous  eruptions.   Dr.
Knapp gives  the  details of several  cases
of intermittent fever and pneumonic affec-
tions in  which  he derived  much benefit
from this remedy, employed as a diapho-
retic.
   When  administered as  an emetic,  it
should be given in powder, in  doses  of
from fifteen to thirty grains.  Where its
hydragogue or diuretic effects are desired,
the best  form is the  decoction,  made  by
boiling an ounce  of the root in a pint of
water, of which the dose is  about a wine-
glassful two or  three times a day.  The
watery extract wil 1 also act  upon the bow-
els, in doses of from  three  to five grains,
but not as efficiently as the  decoction.
   Besides the value of this plant as a the-
rapeutic  agent,  it  is entitled to notice  for
utility in the  arts.  ,The bark furnishes a
fibre resembling hemp,  but of a whiter
colour and much superior in strength and
durability, and a  decoction of the whole
plant gives permanent brown and  black
dyes, according to the mordant used.
  Bibliography.—M. L. Kxapp.  Inaug. Diss.
on the properties of the Apocynum Cannabinum.
American Med. Review and Journal.  Philada.
1826.
  Merat et De Lens.  Diet Universal de Mat.
Med. I. 368.  Paris, 1829.
  J. Curtis.  The Botanical Magazine,  t. 280.
London.
  E. C. Genet.   Transactions of New-York So-
ciety for promotion of useful arts.  III. 153.
  J. H. Griscom. Observations on  Apoci/num
Cannabinum. Amer. Journ. Med. Sciences. XII.
55.   Philada. 1833.
  Wm. Zollickoffer.  On Apocynum Andro-
smmifohum.  Amer. Journ. Med Sciences.  XII.
378.  Philada. 1833.
  Bigelow. American Medical Botany. 11.148.
                      R. E Griffith.
   APONEUROSIS.  (From arto,  from,
and  veveov,  a  nerve.)  This epithet was
bestowed  by  the  ancients  on  the white
fibrous membranes, which  they regarded
as nervous expansions.  The general con-
sideration of these membranes, will be en-
tered into in the article on the fibrous tis-
sues, and the individual aponeuroses or
fascia will be described in connexion with
the regions  they occupy.         I. H.
  APONEUROTIC. Appertaining to the
aponeuroses.                    I. H.
  APOPHYSIS.  (From ano, from, and
$du, I rise.)   A process of a bone
  Apophyses  of Ingrassias,  the lesser
wings of the sphenoid bone.      I. H.  /
  APOPLEXY.  (From  the Greek a*o-
TtXrjaau, or aTtoiCKneoiiv, to strike, or smite,
or to knock  down suddenly or violently.)
artortAjyl'ia, Gr.; Apoplexia,  Lat.;  Apo-
plexie, Fr.; Schlagfluss,  Ger.; Apoples-
sia, Ital.;  called also, by some of the older
writers,  Sideratis, or planet-struck;  or
tufyovtrtoi,  attonitus, or thunder-struck;
and by the French, coup de sang, or rush
of blood.
  The term apoplexy, from its etymology,
would  be  applicable  to almost  every dis-
ease which attacks suddenly and with great
violence;  it is most  commonly, however,
restricted to an affection of the brain, giv-
ing rise to a sudden deprivation, more or
less complete, of the functions of sensation,
voluntary motion, and of the intellect, while
those of respiration  and circulation still
continue, though generally with diminish-
ed vigour.  It  is in this  sense, the term
will be employed in the present article.
  The affection of the brain in apoplexy,
being,  in  the  majority of cases, attended
with an effusion of blood into the substance
of the organ, in the ventricles, or between
its membranes, the term cerebral haemor-
rhage has been proposed by some writers
as a more definite  and appropriate appel-
lation,  and by  others  the term apoplexy
has been extended to all effusions of blood
into the texture of the different organs of
the body, especially into the lungs; hence,
the  expressions pulmonary and  cerebral
apoplexy are in common use.
  From the  earliest periods, the phenome-
na attendant upon an attack of apoplexy
have very forcibly arrested the attention
of the  medical  profession.  The disease
is distinctly  noticed by Hippocrates, un-
der various  points of view, and it is de-
cribed  by the Greek, Roman, and Arabian
physicians with a degree  of minuteness
and  accuracy that have scarcely been ex-
ceeded in modern times.   As might how-
ever be expected, from their ignorance of
the  structure and  functions of the brain
and  nervous system generally, the notions
of the ancients in regard to the pathology
of apoplexy  were confused and altogether
absurd.   It was not until about the seven-
teenth  century that  the morbid appear-
ances discovered in  the  brains of those 
202                       APOPLEXY. (Description.)
 who died after an attack of the disease,
 were  studied with  any degree of  care;
 and to the accounts of those appearances,
 furnished to us by the medical writers of
 that, and the first part  of the succeeding
 century, but little has  been added by the
 laborious researches of subsequent patho-
 logists.  In the first six or seven  epistles
 of the work of Morgagni (De Sedibus et
 Causis Morborum,)  will be found  some
 very interesting notices of the autopsical
 investigations of apoplexy by the physi-
 cians of the period just referred to.   It is
 only, however, very recently, that the real
 character of the lesions of the  brain re-
 vealed by dissection and the relation which
 exists between  them and the symptoms
 which characterize the  disease have been
 accurately examined, and an approach has
 been made towards a correct theory of its
 nature and causes:  it is nevertheless true,
 that  upon many points  connected  with
 its pathology we still  remain in entire
 ignorance.
   Description of the disease.  Although
 in the majority of cases  the invasion of
 apoplexy takes place suddenly, while the
 patient is apparently in  a  state of  perfect
 health, yet  in numerous instances, partic-
 ularly in a first attack, it  is preceded, for
 a longer or shorter period, by certain symp-
 toms which indicate the existence of more
 or less irritation and congestion  of the
 brain.   These  symptoms are pain, or a
 sense of weight and fullness of the head,
 ringing in the ears, vertigo, a tendency to
 sleep,  flushing of the face, a turgescence
 of the jugulars, a throbbing of the  carotid
 and temporal arteries, suffusion of the con-
 junctiva, sparks and flashes before the
 eyes, temporary blindness, particularly in
 a stooping position of the  body, imperfec-
 tion  or loss of hearing, and  a  sense of
 numbness or formication in different parts,
 especially in the extremities. These symp-
 toms are occasionally relieved, either par-
 tially or completely, by a  discharge of
 blood from the nostrils, and the apoplectic
 attack is suspended for a season, or entire-
 ly prevented.  In other cases, in addition
 to the foregoing premonitory symptoms,
 slight convulsive movements of the  mus-
 cles are observed, with involuntary grind-
 ing of the teeth, loss of memory, stammer-
 ing or imperfect  articulation; sometimes
confusion of ideas, indicated by incoherent
discourse; disturbed sleep, hurried respira-
tion, a feeling of weight or of uneasiness
at the precordia.  In many instances, the
disease is ushered in by nausea and vomit-
ing.  It is proper, however, to remark that
no one of these symptoms is found to pre-
 cede the occurrence of apoplexy with any
 degree of constancy.   In very many cases
 they are all of them entirely absent, while
 the majority of them frequently take place
 without being followed by an apoplectic fit.
 Of sixty-nine cases of apoplexy,  of which
 Rocnoux has collected the histories, eleven
 only presented any precursory symptoms,
 and in five of these, the patients  had been
 habitually  subject  to vertigo, which was
 not sensibly augmented  previously to the
 occurrence  of the  disease; hence, he re-
 marks, correctly speaking, in six of the pa-
 tients, only, the precursory symptoms were
 present. (Recherches sur VApoplexie.)
   When seized  with apoplexy, the pa-
 tient falls   down   suddenly,  and is de-
 prived  entirely of sensation, voluntary
 motion,  and consciousness.   Sometimes,
 however, the  attack  is less intense, and
 the patient retains some degree of con-
 sciousness, is still sensible to impressions,
 and capable, to a certain extent of volun-
 tary motion.
   In other instances, the patient experi-
 ences suddenly a deep-seated pain in the
 head, tremor of the limbs, confusion of ideas,
 with pallor of the face, vertigo, and nausea
 or vomiting. These symptoms are soon fol-
 lowed by a state of insensibility, the pa-
 tient being attacked as it were with  syn-
 cope. From this he recovers, after a short
 period, so far as to be able to converse, and
 perhaps to walk about, but still complains
 of pain and uneasiness of the head, with
 confusion of mind and  vertigo.   In the
 course of a few hours, he again sinks gra-
 dually into a state of complete stupor.
   In  other  cases,  the  patient   becomes
 suddenly affected  with  a   paralysis  of
 one side of his  body,  attended with loss
 of speech,  pain  of the head, vertigo, and
 dullness or confusion of ideas;  but the
 sensorial powers  and consciousness  still
 remain.  By degrees, however, these be-
 come extinct, and a state of complete apo-
 plectic stupor finally ensues.
   During a fit of  apoplexy, the patient
 lies in  a  state of coma,  more or  less
 complete.  The face is commonly of a
deep red or livid  hue,  and  puffed up or
swollen;  in some instances, however,
 it   is pale,  and   the   features  appear
shrunk.  According  to  Rochoux,  (Op.
 Citat.) one  of  the most constant symp-
toms attendant upon  apoplexy, is a kind
of stupid or vacant  expression of  the
countenance.  Not  unfrequently the mus-
cles on one side  of the face are drawn in
such a manner as to give to  the  features
a kind of sardonic  grin.   The surface of
the body and the  extremities, either re- 
APOPLEXY.  (Description.)                       203
 tain their natural temperature, or are cold
 and clammy; in some cases the whole sur-
 face  of the body becomes  covered with a
 profuse perspiration, which may be either
 warm or cold. According to Dr. Gregory,
 the occurrence of a cold clammy sweat is
 almost always a fatal symptom. (Johnson.
 Med.-Chirurg. Review, Vol. 1.1820.) The
 teeth are firmly clenched,  and  the power
 of deglutition  is  either impeded or de-
 stroyed.
   The pulse  may be slow, full and hard,
 or small and feeble.  In perhaps the ma-
 jority of cases the pulse will be found at
 first to be  regular, strong, full and  slow,
 but as the  disease advances, it  becomes
 weaker and more frequent; and, finally,
 irregular or intermittent. The pulse  being
 at first small,  and afterwards becoming
 very full, Dr. Gregory considers a fatal
 indication.  Landre Beauvais pronounces,
 also, a strong,  hard and full pulse,  to be
 indicative of  great danger, as we  have
 then to fear a continuance  or quick return
 of the haemorrhage from  the  vessels of
 the brain.  In  extreme cases, in which
 death takes place within a very short pe-
 riod, the  pulse from the beginning of the
 attack is  imperceptible, or nearly so,—the
 heart appearing to be paralyzed in common
 with the voluntary muscles.
   The eye-lids  are  commonly half un-
 closed ; the eyes are injected with  blood,
 or they are dull and glassy; in general,
 the ball of the eye is fixed; in many  cases,
 however, it is observed to  roll about in its
 socket.   In most  instances the pupils are
 dilated;  one pupil may, however,  be di-
 lated, while the other is contracted;  the
 pupils sometimes dilate and contract alter-
 nately, with great quickness, and, as it
 were, spasmodically,  without being  influ-
. enced by the stimulus of light. In  a few
 cases, the pupils, in place of being dilated,
 are contracted almost to  a  point.  This
 condition of the  pupils, though  pointed
 out long  ago  by AretjEus, and more re-
 cently noticed  by  Cheyne  and  Cook,
 seems to have  escaped the attention of
 most writers on the disease.  Dr.  Cook
 considers it to be  among  the  most  fatal
 symptoms;  never having known a  pa-
 tient to recover, in whom it was observed.
 ( Treatise on Nervous diseases.)
   The respiration is slow and irregular,
 and in most cases, it soon becomes ster-
 torous ; but occasionally, the breathing is
 perfectly natural.  The presence or ab-
 sence of stertorous breathing was  sup-
 posed by Boerhaave,  Portal, and by
 many of the more recent  writers, to fur-
 nish  an invariable indication  of  the in-
 tensity or mildness of the  attack.   Such,
however,  is not the fact.   In many pa-
tients, the breathing is very laborious, and
yet  complete recovery quickly ensues;
while in others, an almost natural state of
the respiration may accompany an attack,
which terminates rapidly in death.  In the
more violent cases of apoplexy, expiration
is often attended by a puffing motion of the
lips, as  in smoking a cigar; and a frothy
saliva is blown out with a sputtering noise.
  The bowels, during the  continuance of
apoplexy, are  generally torpid; but occa-
sionally an involuntary discharge of  their
contents takes place.  This  generally de-
pends upon a paralysis of the  sphincter ani,
and is to be considered a very unfavourable
symptom. (Cruveilhier.  Anat. Patholo-
gique.)  The urine  is very frequently
discharged involuntarily.  In some cases,
however,  from paralysis of the bladder,
the urine is retained.   This,  likewise, is
considered an unfavourable circumstance.
(Rochoux.) Although, during an apoplec-
tic attack, the whole body is affected  with
a loss of sensation and of voluntary motion,
this loss is most frequently observed to be
more considerable on one side than on the
other; and, in such cases, when the patient
recovers from the comatose state, it will
be found,  very generally, that the muscles
on  the side most affected  remain  com-
pletely  paralyzed.  The  muscles  of the
extremities, on one side of the body, are
now and then, during the fit, affected with
slight convulsive movements.
  The  duration of the  apoplectic stupor
varies from a few hours  to many days.
Death may  occur in the course of a few
hours, without the patient recovering from
the state of coma.  In this  case, the stupor
becomes more and more intense; the pulse
small, irregular and frequent, and the re-
spiration  slow, short  and interrupted by
long  intervals.  Cases  of  instantaneous
death from  apoplexy are extremely rare;
life being seldom destroyed before the ter-
mination of three or four hours. (Rochoux.)
  When  the case terminates  favourably,
the symptoms slowly and gradually abate,
and the patient regains finally his ordinary
state  of health;  or, as more frequently
happens,  the  stupor disappears entirely,
but the  muscles of one side of the body, or
of a particular part, remain paralyzed, and
may either continue in this conditiqn for life,
or, under an appropriate treatment, regain
gradually their powers.  In some instances,
as the  apoplectic  symptoms disappear,
those of  cerebral inflammation present
themselves, attended with  more or less of
increased  action of the general circulatory
system.   In other cases,  the apoplectic
seizure  is succeeded by extensive para- 
204                         APOPLEXY. (Causes.)
lysis; the affected limbs becoming greatly
emaciated, while the faculties of the mind
are much impaired; the  patient laughing
or crying when spoken  to, without any
assignable cause, and apparently  without
any motive.  (Rochoux.)
  After all cases of apoplexy there is a dis-
position to a recurrence of the disease; the
number of attacks, and the period of their
recurrence, being uncertain.  In most in-
stances the  patient is sooner or later de-
stroyed, or remains  a helpless paralytic
for  life.   Many  survive  a considerable
number of slight  attacks, but  the  more
severe commonly prove fatal on the second
or third  occurrence; thus verifying,  in
some degree, the popular remark, that the
third attack of apoplexy always kills the
patient.  (Cluttlrbuck.  Cyclopaedia of
Pract. Med.)
  Predisposing Causes.   Apoplexy is al-
most invariably a disease of advanced life,
seldom occurring  before the forty-fifth  or
fiftieth year.  No age, however,  is ex-
empted from  it;  but, in  young persons,
it  is more  commonly induced by  what
may be  termed  mechanical  causes;  or,
it comes on in them gradually, and not
as in those of more advanced years, by a
sudden and  unexpected  stroke.  Hippo-
crates (Aphorismi. Sec. VI. 57.) has laid
down the period between the ages of forty
and sixty, as that when the occurrence of
the disease is  the most frequent.   From
later observations, however,  it  has been
shown, that it  attacks as frequently, if not
more so, beyond as within this period. Of
thirty cases which fell under the notice of
Morgagni, seventeen were  in  persons
above  the age of sixty,  and but five  in
those below forty years of age.  Rochoux
gives a table of sixty-nine cases; of which
thirty-seven, or more than half, occurred
after the age  of sixty years; twenty be-
tween  forty and sixty, and the remaining
twelve between twenty and thirty.  The
fact of the more  frequent occurrence of
apoplexy after the age of sixty,  than  at
any other period of life, is stated by Cul-
len, and  repeated  by Portal.  (Obs. sur
V Apoplexie.) It is not, however,  confirmed
by the bills of mortality  for Philadelphia
and  its suburbs.   These  give 577 deaths
from apoplexy  during the ten years, end-
ing on the first of January, 1835; of which,
197 were in persons beyond sixty; 209  in
those between forty  and sixty;  142  in
those between twenty and forty, and 29 in
those below twenty years.
  Apoplexy is of more frequent occurrence
in the male than in the female  sex; pro-
bably from the former being  much  more
addicted than the latter to excesses, both
as it regards the body and the mind.  Of
51 apoplectic patients, admitted into the
General Hospital of Hamburg, during the
years 1828 and  1629, fifteen only were
iemales.  In Berlin, in the year 1829, of
699 deaths from apoplexy, 409 took place
in males, and 290 in females.  In Phila-
delphia, during the three years preceding
1835, the number of deaths from apoplexy
was 209; of these, 119 occurred  in males,
and 90 in females.  M. Serres, however,
found, that to the particular form of apo-
plexy, denominated by him meningeal,
(that  is, apoplexy without paralysis,) fe-
males are much  more liable than males.
Out  of forty-one  cases, of this  species,
which fell under his notice, thirty-three
were  in females, and only eight  in males.
And the registers of the Salpetriere and
Bicetre make the predominance still great-
er on  the side of the female sex.
  Persons ofa plethoric habit of body, with
a large  head, short thick neck, florid com-
plexion, broad shoulders, low stature, am-
ple chest, globular abdomen, and general
inclination to obesity, are those most pre-
disposed to apoplexy.  These features con-
stitute what Bricheteau denominates the
apoplectic  form.   " If with  these (says
Bombier) are associated those habits which
make the head a centre of excitement for
vascular fluxion, at the same time that the
other organs are left inactive, the sensorial
functions  acquire a remarkable  predomi-
nance in  strength and  activity; but too
often  to the destruction of the individual.
This is  frequently exemplified in the per-
sons of such as  give  themselves up  to
immoderate study, uninterrupted by a suf-
ficient  quantum  of sleep and muscular
exercise." (Considerations et Observ. sur
V Apoplexie.)
  Most writers agree  with Cullen  in
considering excessive obesity among the
predisposing causes of apoplexy,  in conse-
quence of its impeding the free passage of
the blood through the lungs.  In the 69
cases  detailed by Rochoux, the  majority,
nevertheless, (namely, 42) occurred in sub-
jects presenting no remarkable degree of
obesity; 10 only were in fat and  plethoric
subjects, and 17 in meagre subjects.
  A sedentary and inactive life, with a full
nourishing diet; too great an indulgence
in sleep;  venereal excesses, especially in
those  advanced  in years, and a change
from an active or laborious to a quiet and
indolent mode of life, are well-known pre-
disposing causes of apoplexy.  A  predis-
position to the disease is likewise produced
by intense thought, prolonged study, or by 
APOPLEXY. (Causes.)
205
the habitual indulgence in any of the more
absorbing passions or affections of the mind.
The influence of a meditative and studious
life, in the production of the disease, is
evinced, according to Ponsart, by a much
greater number of monks and financiers be-
coming apopletic than of peasants.   While
we admit, however, the injurious effects
resulting from  too intense and prolonged
an application of the mind, to the neglect
of bodily exercise, we conceive the remark
of Rochoux to be fully substantiated by
facts; namely, that intellectual pursuits,
generally speaking, so far from predispos-
ing to apoplexy, are rather a preservative
from the disease.
   It  has been  remarked, that apoplexy is
frequently brought on by the sense of deep
chagrin  and mortification, which  aui am-
bitious and  proud mind experiences when
it fails in attaining  some much cherished
object, or suffers a great and  unexpected
reverse of  fortune.   Thus Fourcroy was
seized with apoplexy, in consequence of
the cruel mortification which he experi-
enced in not being  named Grand Master
of the Imperial University;  and the same
occurred to Chaussier, when he  was de-
prived of  his  chair of professor  in  the
faculty of medicine  at Paris.
   According to  Hippocrates, and  the
majority of the Greek physicians,  cold
and  moisture,  or sudden  atmospherical
vicissitudes, are to be ranked among the
predisposing causes of apoplexy. A similar
statement is also made by Baglivt, Fores-
tus, Morgagni, Richter, and most subse-
quent writers on the disease.   Rochoux,
however, doubts the fact of season, climate,
or atmospherical vicissitudes, having any
influence  in its  production.  In  the 69
cases of which he collected the histories,
16 occurred  in spring,  19  in summer,
18 in autumn, and 16 in winter.  An in-
creased temperature of the atmosphere
would, certainly, appear more frequently
to predispose to apoplexy than the opposite
condition.   Thus,  according  to  Frank,
(Prax. Med. Univ. Prcecep.  I. 308.) apo-
plexy occurs most frequently at Wilna and
St. Petersburgh during the greatest heats
of summer.  Exposure to extreme degrees
of cold has undoubtedly a tendency to in-
duce a kind of apoplectic sleep, from which
the person seldom, if ever,  awakes; but
this condition can scarcely be considered
as identical with apoplexy.
   Agreeably to the observations of Qua-
rin,  apoplexy is much more common in
cities than in the country.   This might
readily be anticipated, when the life and
condition of the agricultural classes, gen-
  VOL. II.           18
erally speaking, are contrasted with those
of nearly every class of citizens.
  Of all the predisposing causes of this
disease, none, perhaps, is more general or
efficient than the habitual indulgence in
distilled, vinous,  or  malt liquors.  "The
daily use," remarks Cheyne, " of wine or
spirits, even in what is considered a mode-
rate quantity, will lead a man of a certain
age and constitution to apoplexy, as cer-
tainly  as habitual intoxication;" and  he
adds, "in nineteen cases out of twenty,
the disease may  be  averted or postponed
by temperance."
  A state of pregnancy is  considered  by
Meniere (Archives  Gen. de Med.  XVI.
489.) as predisposing to apoplexy.   But,
as Rochoux very properly remarks, this is
disproved by the  disease more frequently
occurring after than before  the fortieth
year, consequently subsequent to the pe-
riod when pregnancies are most common.
There is no doubt, however, that, during
the puerperal state, females are in some de-
gree predisposed to apoplexy.  Dr. Davis,
of London,  states that  he has met  with
four or five apoplectic attacks followed by
hemiplegia  in  puerperal females.  In all
these cases, the patients presented the true
apoplectic phenomena.
  The poor are equally liable to the attacks
of apoplexy  as the  rich.   Sir  Gilbert
Blane has even  observed, from accurate
tables, derived from a practice of ten years
in St. Thomas' Hospital, London, and his
private  consultations, that there is a con-
siderably greater  proportion of apoplexies
and  palsies among the poor than among
those in  affluent circumstances; or, in
other words, that these diseases bear a
larger proportion  to other maladies among
the poorer classes, than among those in
high life.  " Some cases of hemiplegia,"
he observes, " occur  in  full habits; some
in spare and exhausted habits.  The former,
being most  incident to the luxurious and
indolent, more frequently occur among the
upper  ranks of life.  The  latter  occur
more among the impoverished classes, and
among such of  the rich as are addicted to
exhausting pleasures."  (Trans. Medico-
Chirurg. Soc.  IV. 124.)
  Various diseased conditions of the heart,
especially hypertrophy,  have been  found
to predispose the individuals in whom they
occur to an attack of apoplexy.  This fact
is attested by Le Gallois, Pariset, Cor-
visart, Testa, Bertin, Hope, Cruveii.-
hier, and others.  In support of it, a series
of very interesting observations are pre-
sented byBRiCHETEAU and Ravier. (Journ.
Complem. IV. 17. Theses de Paris.  1821. 
206
APOPLEXY.  (Causes.)
No. 14.)  According, however, to Lalle-
mand, when, in addition to the hypertrophy
of the heart, there exists also any obstacle
to the free  passage of the blood into the
aorta, the tendency to an apoplectic seizure
will be prevented.  Of forty-two apoplec-
tics,  whose bodies were examined  after
death by Rochoux, three  only presented
an aneurismal condition of the heart.   But
Andral is  of opinion, that these dissec-
tions cannot be adduced to disprove the
fact of the  intimate  connexion between
disease of the heart and apoplexy; hyper-
trophy, with diminished size of the  ven-
tricular cavities, being a disease that was
but little known at the period when they
were performed, its existence may  have
been overlooked in some  of the cases.
Richond conceives that both the disease of
the heart and that of the brain, when they
are found to coexist, are to be referred to one
and the same cause, an irritation, namely,
of the mucous membrane of the stomach.
   Nearly all the chronic affections of the
brain may be ranked  among  the predis-
posing causes of apoplexy.  Thus in epi-
lepsy, chorea, and certain forms of mania,
death is frequently caused by the occur-
rence of an apoplectic attack.   But among
those morbid conditions of the brain, which
most frequently predispose to the occur-
rence of apoplexy, is a diseased state of
its vessels,  consisting  in a peculiar  fria-
bility or brittleness of their coats, from a
calcareous  deposit to a greater or less
extent into the tissues of the latter.   This
condition of the  vessels, the tendency of
which to induce aneurism and haemorrhage
has been clearly demonstrated by Scarpa,
is very commonly met with in the brains
of elderly persons; and its agency in the
production of apoplexy, is pointed out  by
Cruveilhier, Abercrombie,  and  other
writers on the disease.
  Wepffer, Forester, Dreysig, Por-
tal,  Frank, Van  Hooven,  Blane, and
others, adduce numerous cases of apoplexy,
falling under their own notice, which seem
to show that the disease, in many instances,
must  be considered to be an hereditary af-
fection.  Several striking instances, of a
similar  character, have come within our
own  knowledge.  The  general  fact  is,
however, denied  by Rochoux.   But we
believe there can be little doubt that the
peculiar  conformation and  habit of body
which predispose to  apoplexy,  may  be
transmitted  in  particular  families;  and
this is all that is meant when the disease
is said to be hereditary.
  According to Baglivi, apoplexy has oc-
casionally prevailed epidemically.   The
same fact is  also  stated by Morgagni,
Hoffman, Richter, Weikard, Jahn,Thi-
lenius, and others.   (Richter.  Specielte
 Therapie. VIII.)
   Certain professions or occupations are
said unquestionably to  predispose to the
disease; particularly such as expose the
individuals  engaged  in  them  to the in-
halation of metallic and other deleterious
gases.
   Exciting Causes. The continued action
of many of the predisposing causes already
enumerated, will often be sufficient of it-
self to induce an attack of apoplexy. Thus,
not unfrequently the patient is seized in
the midst of his ordinary occupations, even
when not subjected to any unusual fatigue
or exertion.   In  other  cases the attack
takes place during sleep,  or  when  the
patient  is conversing with the  utmost
calmness, and without,  apparently,  the
brain or heart experiencing any unusual
excitation.  But there are certain causes
by which apoplexy may be produced, to
the influence of which the patient is sub-
jected only a short time before the occur-
rence of the disease.  It is to these  the
term  exciting  causes is most  generally
restricted.  The latter, however, Will  sel-
dom cause an  attack unless the brain is
already  predisposed to  disease.  Among
these causes may be enumerated what-
ever has  a  tendency to  impede the free
return of the blood from the head;  to pro-
duce a sudden  or violent excitement of the
mind, or to induce irritation of the brain,
or of its  membranes,  either directly or
indirectly. Thus the disease is frequently
brought on by wearing tight clothing, es-
pecially such  articles of dress" as press
upon  the  vessels of the  neck, or impede
the free expansion of the  chest; by an
overloaded condition of the stomach; by
violent  straining,  particularly  in  lifting
heavy weights; by blowing wind-instru-
ments, or any other cause  by which  the
free passage of the blood through the ves-
sels of the lungs is, for a time, prevented.
Tumours  in the neck, pressing upon  the
jugular veins, obliteration of the  latter,
from inflammation of their  coats, as well
as obliteration of the occipital; parietal,
and mastoidian veins, by which the com-
munication between the external and inter-
nal veins of the cranium is destroyed,  are
considered by Morgagni, and, more recent-
ly, by Cruveilhier, to be not unfrequently
causes of apoplexy.  Cullen enumerates
among the exciting causes of this class,
stooping down, with the head towards the
ground, and other situations of the body
in which  the head  is kept for some time 
APOPLEXY. (Causes.)
207
in a depending  position.   According  to
Portal,  tumours  of considerable size,
within the abdomen; and ossifications of the
thoracic and ventral  aorta, as well as  of
the arteries of the extremities;  of the su-
perior cava, or of the right ventricle and
valves of the  heart, by the  impediment
they present to the free circulation of the
blood, act occasionally as exciting  causes
of apoplexy.  (Resultes de Voverture des
corps.)  The agency of some of the above
circumstances, in  the production of  the
disease, will admit of considerable doubt;
while it is probable that  others of them
produce an attack,  not  as  is  generally
supposed, merely  by inducing, mechani-
cally, venous congestion of the  brain, but
by causing irritation of some  portion of its
substance, or of its membranes.
   The exciting causes of apoplexy, which
act  by  producing  a  sudden  or powerful
impression upon the brain, are  fright, ex-
cessive joy,  a violent fit of anger,  the
venereal orgasm,  or any  powerful shock
to which the feelings may be unexpectedly
subjected.
   Among the causes which bring on an at-
tack of the disease, by causing irritation of
the brain or of its membranes,  directly or
indirectly, is, intemperance in  eating and
drinking. Sir A. Carlisle presents a case
of apoplexy, caused  by the drinking of an
immense quantity of gin, the odour of which
was detected, on inspection, in the serum
of the ventricles of  the brain.  Wepffer
(Obs. Medico-Prac.  Page 7.  1722.)  and
Schroder (Obs. Anat. Med.  Decad. IV.
1674.) relate similar cases.  The  fact is,
the  condition of the brain, as well as  the
external phenomena produced by extreme
inebriation, so nearly resemble  what takes
place in apoplexy, that it is very difficult,
in many cases, to distinguish the one from
the other.  In general, however, the appli-
cation of some  powerful irritant to  the
skin, as sinapisms or the actual cautery,
will quickly rouse the inebriate, but will
have very little  effect upon the individual
affected with  apoplexy.   From a state of
complete intoxication, induced by large
quantities of ardent spirits, many individu-
als never recover; death  being produced
by a true apoplectic seizure.  Apoplexy
may likewise be brought on by late sup-
pers, particularly of stimulating and  in-
digestible food.  According to Portal and
Rochoux, the disease is found to be of
much less frequent occurrence in Paris
since the practice of eating heavy suppers
has been relinquished.  Among the other
exciting causes which act chiefly upon  the
brain, are, exposure  to the direct rays of
the sun;  falls  or blows upon the head;
concussion or wounds of the brain; violent
exercise, particularly in warm weather;
breathing a heated and impure air, as that
of crowded apartments.  It is well known
that this cause  will produce intense pain
of the head, and a sense of over-fullness in
the vessels of the brain, even in persons
not predisposed to apoplexy.  Erysipelatous
affections of the face and scalp; repelled
eruptions; the  sudden cessation of  any
habitual discharge, especially that arising
from haemorrhodes;  and of the frequent
(sometimes periodical) flow of blood from
the nose, to which plethoric subjects are oc-
casionally liable. According to Schmuck-
er, Cruveilhier, and others, the healing
up, without proper precaution, of old  ulcers
has also a tendency to produce an attack
of apoplexy in the predisposed; and Vogel
has noticed a similar effect from the neglect
of customary venesection in persons of full
habits.   The truth of this is confirmed by
Cruveilhier.
   Apoplexy is likewise not unfrequently
brought on by the incautious treatment of
long-continued  discharges from the ears,
causing their  sudden stoppage.   Inflam-
mation has also been known to extend, in
cases of violent otitis, from the internal
structure of the ear  to  the brain, and in
this manner, give rise  to apoplexy.  In-
stances of this  are related by Lallemand,
Gendrin, Itard, Krukenberg, Copland,
and others.
   The  most frequent, however, of the ex-
citing causes of apoplexy, is unquestionably
irritations of the gastro-enteric mucous
membrane.   Many of the causes already
 enumerated  exert evidently their morbid
 effects  first upon the stomach and  small
 intestines, from which organs the irritation
 excited by them is subsequently trans-
mitted  to the   brain.   This is especially
 the case in  reference to intemperance  in
eating and drinking, the use of indigestible
food, a  too free indulgence in condiments,
and other stimulants; a sedentary, indo-
lent, and luxurious mode of life, &c.  And
it is by exciting irritation of the stomach
and bowels, or by augmenting that which
already exists, that  the  use  of certain
mineral waters, and other irritating reme-
dies, as emetics, purgatives, tonics, and
 the like, are too often fatal to persons pre-
disposed  to apoplexy, or labouring under
some degree of paralysis.  The connexion
between irritations  of  the stomach and
apoplexy was not entirely  overlooked by
former  writers.  It is noticed, among others,
by Baglivi, Schroder, Barthez, Schaf-
 fer, Tissot, Schenk, Fothergill, Hoff- 
208
APOPLEXY.  (Causes.)
man, Thilenius, Van Sweiten, and more
recently, by  Hufeland, Louyer, Fode-
re, Villermay, and Chomel ; but  it is
chiefly to the writings of Broussais, and
the very excellent treatise of Richond,
(De  Vinfluence de VEstomac sur la pro-
duction de VApoplexy,)  that we are in-
debted for  the  full establishment of the
fact and the important indications which
it presents in the prevention and treatment
of the disease.   It is by the tendency of
the brain to suffer from irritations prima-
rily  seated in  the digestive canal,  that
we are  to explain  the  liability to  apo-
plexy of persons labouring under hepatic
disease,  noticed by Stoll,  Baldinger,
Cheyne, Copland, Tivenins, &c. ; affec-
tions of the liver being almost invariably
attended by very considerable gastroente-
ric irritation; of which latter it is in fact
often merely the  sequel.  In  the  same
manner may also  be explained the fre-
quency with which apoplexy occurs  in
persons of what are termed a gouty dia-
thesis.  The brain may also occasionally
suffer  from  external  irritations.   Thus
metastasis  of rheumatism, in particular,
will  often  produce an apoplectic attack.
Cases of this kind are related by Morgag-
ni, Hoffman, Wiekand, Stoll, Ville-
neuve, and a number of other writers.
  Apoplexy sometimes occurs  during the
severe and  protracted chill with which
certain  forms of  intermittent  fever  are
occasionally attended.  In such instances,
the apoplectic  seizure  is said to be,  in
general, comparatively light, and neither
attended with nor followed by paralysis.
Though, as  a  general  proposition, this
statement may be  correct, yet  cases  do
occasionally occur in which the  attack is
so intense as to produce almost immediate
death ; and Copland refers to an instance
that  fell under  his own notice, in which
paralysis supervened upon  the apoplectic
seizure.  (Diet, of Pract. Med.  London,
1833.)
  The association of apoplexy with disease
of the kidneys has  been noticed by several
writers, particularly Bonet, Littre, Mor-
gagni, and Bright.  The occurrence of
apoplexy, particularly that  form attended
with serous  effusion in the brain, after
suppression of  urine,  is not uncommon.
By some authors the suppression has been
imputed to pre-existing disease of the brain.
In a great majority of cases, however, the
kidneys and  ureters present evidence of
having been the parts primarily affected.
The experience of Bonet and Morgagni,
and of numerous late writers, would appear
fully to support this conclusion.   The oc-
currence of apoplexy, as a consequence of
organic change in the secreting structure
of the kidneys, by which their functions
are more or less obstructed, has been fully
illustrated  in  the cases  reported  by Dr.
Bright. (Copland.)
  The  influence of narcotics, in large
doses,  in the  production  of  apoplexy, is
noticed by  various  writers.   Gregory,
however, doubts  whether they can ever,
with propriety, be considered  as exciting
causes of the disease. We cannot conceive
that there  can exist any just ground for
doubt concerning the fact: we have our-
selves seen, in more  than one instance, an
over-dose of opium produce all the symp-
toms of the disease,  followed  by death;
the brain exhibiting, upon dissection, ex-
tensive congestion of its vessels,  and in
one  case, extravasation of blood.   Cop-
land  relates  the case of a  young man,
who, shortly after incautiously chewing
some   seeds  of  the monk's-hood,  Was
seized witli a sense  of numbness in the
face,  succeeded  by  complete apoplexy,
from which  he was  recovered with great
difficulty, but with paralysis of one side of
his body, with which he was  still affected
when  upwards  of   a  twelvemonth  had
elapsed from  the period of the  attack.
(Diet, of Prac. Med. p.  92.)  Apoplexy
lias likewise been excited by tlie inhalation
of carbonic acid gas  and certain mephitic
vapours.  And we saw,  in one instance,
the disease  produced by the inhalation of
vitrolic ether; from  which, however, the
patient (a young female) was promptly re-
covered by the ordinary remedies.
  Within a few  years, the production of
apoplexy has  been  attributed, in  certain
cases,  to profuse haemorrhage, or to the
artificial abstraction  from the veins  of
large quantities of blood.  It is certainly
a curious fact,   established,  some  time
since,  by  the observations of  Saunders,
Seeds, and  Kellie,  upon animals bled to
death, that the brain will very often pre-
sent a loaded state of its vessels, and more
or less serous effusion into its ventricles,
even in cases  in which the patients  have
been destroyed by excessive loss of blood.
But whether, in any  case, a congestion of
the brain can be produced  in this  way,
sufficient to give rise to an actual attack "
of apoplexy, is very doubtful.  Patients,
we are told by Mr. Hall, who has written
the most extensively on this subject, are
sometimes so comatose after profuse blood-
letting or  haemorrhage, that  it may be
doubted whether the case be  not one of
apoplexy.  But we conceive that the line
of  distinction, between  such  cases and 
APOPLEXY. (Anatomical Lesions.)                   209
 genuine apoplexy, is clearly and strongly
 marked.  Nevertheless attacks of apoplexy
 have indisputably occurred after extensive
 losses of blood.   Thus Denman relates an
 instance, in which a female, who was great-
 ly exhausted  in consequence of repeated
 haemorrhage from a fungous tumour of the
 uterus, was suddenly seized with apoplexy.
 Hay also, in his work on puerperal fever,
 cites the case of a  female, who, after be-
 ing relieved  of  that disease by free and
 repeated bleedings, became affected with
 symptoms of cerebral congestion, followed
 by  permanent paralysis.   Dr. Tweedie
 states that a female, who was much  ex-
 hausted  by frequent and profuse  hemor-
 rhage  from the  uterus,  during the  last
 months of pregnancy, when first permitted
 to sit up, after delivery, became paralytic
 on the right side.  The paralysis gradually
 disappeared; but during a journey to Brigh-
 ton, she suddenly became insane.  A case
 is likewise given, by Mr. Hammond, of a
 parturient female, who lost about three
 pints of  blood after the  expulsion of  the
 placenta.  Subsequently she became affect-
 ed with severe pain of the head; for which
 she was  bled, cupped, and purged very
 freely.  The  bleeding was carried at one
 time to the extent of twenty-four ounces,
 and was afterwards repeated to the amount
 of twenty-two ounces, when fainting was
 induced,  and the patient became strongly
 convulsed.  On recovering, the head-ache
 appeared to be relieved; but again return-
 ing,  was treated by two applications of
 leeches to  the head.  On the eleventh
 day, subsequent  to  confinement,  she  be-
 came paralytic on the right side, and her
 voice and deglutition were impaired.   By
 the end of the month,  however, she was
 quite  convalescent.  These  cases,  and
 many others of a somewhat similar char-
 acter that might be cited, prove, we admit
 that apoplexy  and paralysis may occur in
 patients whose general system is in a state
 of extreme exhaustion, from loss of blood,
 or other  evacuations ;   but they by  no
 means establish the fact, that the  disease
 of the brain  upon which the  apoplectic
 attack depends, is the immediate effect of
 the depletion  to  which the patients had
 been subjected.  We are not, therefore,
 prepared  to admit extensive  losses of blood
 among the exciting causes of apoplexy.
   Anatomical Lesions.   As  would   be
 anticipated  from  the character of those
 phenomena which more  particularly char-
 acterize  the disease, on  examining,  by
dissection, the bodies of apoplectic pa-
tients, after death, it  is in the brain that
morbid appearances are the most constant-
                 18*
 ly observed.   Other organs, it is  true,
 often  present  indications of more or less
 disease; but, as these are very frequently
 met with in patients who have not suffered
 from apoplexy, and are as  frequently ab-
 sent in those who have, they may be con-
 sidered either as not at all connected with
 the apoplectic  seizure, or, at least, as hav-
 ing only an indirect  influence in its pro-
 duction.
   After death, from apoplexy, the brain is
 said, in a few cases, to  be found in a per-
 fectly natural  state, and presenting no in-
 dications whatever of its having been re-
 cently the seat of disease. Such instances
 are related by Willis, Stark, Powel,
 Abercrombie, Fodere, Hildenbrand, and
 others. They are, however,  we suspect, of
 extremely rare occurrence.  Of seventy-six
 fatal cases of apoplexy, related in the work
 of Bonetus, (Sepulchretum), all presented
 evident disease of the brain, with the ex-
 ception of one only; and in that the relater
 even doubts whether the death of the pa-
 tient could be attributed to  apoplexy. In
 all  the  cases  reported  by  Morgagni, in
 which the brain was examined by himself,
 more  or less disease of that  organ was
 present.  John Hunter asserts, that in
 all  the  cases  he  had  an opportunity of
 examining, after death, there  existed an
 extravasation of blood in the brain.   Por-
 tal found, in  all his dissections, conges-
 tion of the vessels of the brain, with or
 without effusion of blood or serum. Cheyne
 makes a similar statement.   Dr. George
 Fordyce examined the brains of ninety-
 eight apoplectics and paralytics, and dis-
 covered effusion of blood in all.  Baillie
 likewise noticed effusion of blood in the
 brain  in all the  cases  examined by him.
 Serres dissected the brains of a hundred
 apoplectics: in all, evident marks of dis-
 ease were  present.  But it is unneces-
 sary to  enlarge  upon  this point.    We
 need only refer to the writings of Lalle-
 mand, Bricheteau, Rochoux,  Cruveil-
 hier, and Rostan, for proof of the almost
 invariable occurrence of a morbid state of
 the brain in those who have been destroyed
 by apoplexy.   In some of  the cases in
 which no morbid appearances are reported
 to have been  detected  after death,  it is
 probable, as Bricheteau very justly re-
 marks, that the  lesion of the brain has  been
 actually overlooked; while in others, it is
 possible, that at the moment of, or subse-
 quent to death, the engorgement of the
 cerebral vessels, giving  rise to the  dis-
 ease, was dissipated.
  The post-mortem appearances, ordinari-
ly  detected  in  the  brains of apoplectics, 
210
APOPLEXY.  (Anatomical Lesions.)
may be arranged under five general heads.
1.  Congestion of the vessels of the brain
and of its membranes; 2. Effusion of blood
without any lesion of the substance of the
brain; 3. Eflusion of blood with rupture
or disorganization of the substance of the
brain; 4. Effusion of serum;  5. Various
diseased conditions of the membranes of
the brain, or of the latter, with or without
effusion of blood or of serum.
   1.  General turgescence of the vessels
of the brain. Cases of this kind are related
by Morgagni,Cheyne, Bricheteau, Rich-
ter, Serres, Foquier,  and  others.  The
vessels and sinuses of the dura mater, the
vessels upon the surface of the brain, and
those of the dura mater, are found in many
cases unusually distended with blood, and
occasionally more or less of a bloody infil-
tration into the substance of the latter can
be detected, but unattended by effusion
of blood,  strictly speaking, or by any ap-
preciable lesion of the brain itself.  When,
however, incisions are made into the latter,
the cut surfaces  are found to be studded
with numerous small points of blood, indi-
cating, evidently, an  unusual fullness of
the vessels which penetrate into the sub-
stance of the organ.  This engorged state
of the cerebral vessels is almost always
attended by an engorgement, more or less
extensive, of the vessels of the  scalp and
neck; and not unfrequently large ecchy-
moses exist about the throat and chest.
   In cases of apoplexy  accompanied with
general turgescence of the vessels of the
brain, according to the  observations of
Bricheteau,  the coma is more intense,
and the abolition of the intellectual facul-
ties more complete, than in those attended
with effusion  of blood.   The condition of
the brain above described, is met with in
few,  comparatively, of  the autopsical ex-
aminations of apoplectic subjects, and the
reason is, that it constitutes the least fatal
of all the species of apoplexy—the num-
ber of the patients affected with this con-
gestive form  of the disease who recover,
according to the author last quoted, being
much more numerous than those who die.
In many  instances, however, death en-
sues very promptly.
   In the  work of Morgagni, several cases
are related of apoplectic attacks almost
immediately fatal, in which, after death,
the principal lesion discovered in the brain
was extensive engorgement of its vessels.
This was the case, more especially, in the
instances related in Epis. 3, sec. 26, Epis.
4, sec. 16, 21, 24, 32, and in Epis. 5, sec.
19.   Foquier relates a somewhat similar
case in the Ann. Med. Chirurg. I. 376;
and the ninety-fifth case of Abercrombif.
(Diseases of the Brain and Spinal Cord)
was evidently one of the same kind.
  2.  Eflusion of blood without any lesion
of the substance of the brain.  In cases of
this description, the blood is generally ex-
travasated between the dura  mater and
arachnoid, and  may  be produced  either
by exhalation from the capillary  vessels
of' the membranes, or by rupture of one or
more minute arteries or veins.   Instances
are recorded in which the blood  appeared
to be derived from the retiforme  plexus of
vessels  at the basis of the brain, and was
confined beneath the pia mater.  Bonetus
relates a  case in which a very  extensive
effusion of blood existed between  the pia
mater and the brain, and throughout the
whole extent of the vertebral canal.  The
blood  in  this case  came  from the small
arteries surrounding the basis of the brain,
which are given off from the carotids and
vertebrals. In a case reported by Morgagni,
a great quantity of blood was found in a
coagulated state beneath the arachnoid,
upon the anterior surface of the  brain;
both ventricles  also contained a small
quantity, partly fluid and partly coagulated.
M. Rochoix reports a case of very exten-
sive effusion upon the surface of the brain,
from the rupture of some of the superficial
vessels  of the latter.  Two cases are like-
wise given  in the work of Abercrombie,
in one of which, reported by Dr. Barlow,
a copious extravasation of blood was found
extending over the surface of the brain,
and closely adherent to the  dura mater;
and in the other, reported by Dr. Hunter,
a coagulum of blood covered and  complete-
ly concealed the right hemisphere of the
brain, and dipped down below  its basis.
In both instances, the blood appears to
have  been  thrown  out by  exhalation.
Richter, also, states that he has occasion-
ally found extensive extravasation of blood
beneath the membranes of the  brain, but
makes  no mention of a rupture of any
vessel, or any evident disease of the brain
itself.   In a case recorded by Bang, (Act.
Reg. Soc.  Med. Havn.  1.116.), and in
another  by  Dr. Watts, of  New-York,
(Med. Surg. Regis, of N. Y.), the blood
was effused between the cranium and dura
mater.   Effusions of blood  thus situated
are frequent in apoplexies  produced by
external  injuries of the scull.   (Specielte
 Therapie. VIII. 719.)  In those cases in
which the haemorrhage proceeds from rup-
ture of an artery, all the superficial ves-
sels, according to Serres, are found great-
ly distended, while a  twig  or  branch io
torn partially or quite across. More rarely 
APOPLEXY.  (Anatomical Lesions.)                   211
 he has found a small aneurismal  pouch
 ruptured in the same manner as an aneu-
 rism occurring in any other part of the
 body.  He has also seen the internal carotid
 aneurismal  and ruptured, while yet  in-
 closed in the cavernous sinus; and  subse-
 quently he met with an instance in which
 the aneurism occurred in the basilary ar-
 tery, and in a small artery in the circle of
 Willis. Cases ofa similar kind are related
 by various  other  writers.   The hemor-
 rhage upon the surface of the brain is some-
 times caused by ulceration of the coats of
 an artery.   Dr. Mills  relates a case in
 which it was traced to  ulceration of the
 basilar artery; and Morgagni one, in
 which it arose from  a similar lesion of the
 internal carotid: ulceration was likewise
 the cause of the haemorrhage in the case
 of Dr. Watts noticed above.  Extravasa-
 tion of blood from rupture of the vein6 is
 still more frequent,  according to Serres,
 than from  rupture of an artery.   The ve-
 nous rupture occasionally takes place in
 the choroid plexus, and the blood is inclosed
 in a thin cyst, or  between the lamina? of
 the pia mater.   Cases in which the hae-
 morrhage was traced to  the vessels of the
 choroid  plexus are  likewise related by
 Morgagni,  De  Haen,  Hufeland,  and
 Cruveilhier. This is probably the source
 of the effused blood  when it is confined to
 the ventricles, without  laceration of the
 surrounding substance of the brain. Blood,
 however, is rarely effused, in the first in-
 stance, into the ventricles.   During  ten
 years' observation in the different hospi-
 tals, Bricheteau saw only two instances
 of this:  in these there was no rupture of
 the parietes of the  ventricles, nor of any
 vessel, the blood being thrown out by ex-
 halation.  In general, when the ventricles
 contain blood, it has been extravasated in
 their immediate neighbourhood, and bursts
 into them  through a ragged opening.   A
 very interesting case of extensive hemor-
 rhage into  the ventricles, without lesion
 of the brain or rupture of vessels, is given
 by Aberorombie.
   Rupture of one of the  lateral  sinuses
 has been observed  as the source  of the
 hemorrhage upon the surface of the brain :
 a  case of this description occurred to Dr.
 Douglas.  (Edin. Med. Essays  and Obs.
 V. 602.)
   3.  Extravasation  of blood into the sub-
stance of the brain, with  rupture or disor-
ganization of the substance of the latter.
This is by far  the most  common  morbid
appearance detected in the brains  of per-
sons destroyed by apoplexy.  The blood is
commonly extravasated in some part of the
cerebrum, in the immediate vicinity of the
ventricles, especially in the corpora striata
and thalami optici.  This fact was remark-
ed by Morgagni, and is  confirmed by the
observations of subsequent  investigators.
Thus Rochoux, in forty-one  dissections of
apoplectic subjects, found twenty-six with
extravasations in the corpora  striata, and
two in the thalami, while only thirteen, or
not half the number, were found to be in
various other parts of the brain.  Of three
hundred and eighty-six cases of apoplexy,
with  dissections,  collected by Andral
from different writers, (Anat. Patholog.
II. 758), two hundred and two presented
extravasations of blood into both the cor-
pora striata and  thalami; sixty-one into
the striated  bodies  alone; and thirty-five
into the thalami alone: thus making  two
hundred and ninety-eight in which extra-
vasation existed in this part of the brain.
Of the remaining eighty-eight, in twenty-
seven the extravasation was  in  that portion
of the hemispheres which is situated above
the centrum ovale  of Vieussens ; ten in
the anterior lobe of the cerebrum; seven
in the posterior lobe of the  cerebrum;
nine in the mesocephalum; three in the
peduncula of  the cerebrum;  one in the
pituitary  gland; one in  the corpora oli-
varia;  nineteen in different parts of the
cerebellum; and eight in the spinal  mar-
row.   Cruveilhier has found the extra-
vasation to take  place frequently in the
convolutions  of the' brain.  Serres de-
scribes a case in which it occurred in the
substance of the pons varolii, whence the
blood  had burst  into the occipital fossa.
Extravasation of blood into the cerebellum
is very rare.   Morgagni reports only a
single  instance,  (Epis.   II. 22.),  Heur-
tault relates a case, and Bricheteau saw
a single instance at the Hotel Dieu.  The
man died suddenly, and on dissection, a
considerable effusion of blood was found
in both lobes of the cerebellum.  (Joum.
Compl. Oct.  1818.)  Abercrombie  met
with it in two cases.  Rochoux thinks it
can scarcely occur once  in  fifty patients:
in the  cases reported by Andral, it was
found  in about every 21.42 cases.  The
reason  why  extravasation  should occur
most  frequently  in the  corpora striata,
thalami, and  their vicinity, results,  ac-
cording to Bricheteau, from the number
of arteries which penetrate  directly  into
those  parts, without ramifying  on  the
pia mater, as  the  other  nutrient vessels
of the  brain do;   and   situated,  conse-
quently, in  the midst  of  the  cerebral
substance,  the  consistence  of  which
is  little  capable   of  supporting them 
212
APOPLEXY.  (Anatomical Lesions.)
when over-distended with blood.  (Journ.
Compl.)  In proof of this explanation, he
remarks, that if injections are pushed with
force through the carotids  of young sub-
jects, artificial  extravasations will com-
monly be  produced in this part of the
brain,  as was  already noted by Lalle-
mand.  It is  likewise, according  to the
observations of Cruveilhier, in the corpo-
ra striata or that vicinity, that the effusion
of blood takes place, in cases of concus-
sion of  the brain.  It was the opinion of
Morgagni,  that the effusion of  blood in
cases of  apoplexy took place most fre-
quently upon the right side of the brain.
Rochoux, however, found  that  of forty-
one cases which he examined after death,
in twenty-four, the  extravasation was on
the left side; in twenty-four, on the right,
while in  seventeen, it occurred  on both
sides of the brain.
  The blood, in whatever part of the brain
extravasated, is contained in a cavernous
pouch, which was compared by Wepffer
and  Morgagni  to  an  aneurismal  sac.
When  the  hemorrhage  is recent, the
cavity in  which the blood is accumulated
has an irregular spherical form.   Its pari-
etes are torn and irregular; they present
shreds of medullary matter, either com-
pletely  detached and mixed with  blood, or
adherent  by one of their extremities to
the sides of the cavity.  Surrounding the
cavity, the substance of the brain  is either
perfectly healthy, stained with blood, or it
is softened to the thickness of from half a
line to two lines.  It is  sometimes convert-
ed  into a reddish  paste.   This  softened
state  of the brain in the vicinity of the
extravasation, Rochoux considers to take
place previously to the escape of the blood
from the vessels;  of which, according to
him, it is the cause rather than the conse-
quence ; and  he  refers to  Bichat and
Hodgson,  in  confirmation  of the fact.
Cruveilhier, on  the  other hand,  main-
tains that it takes place subsequently, and
is invariably the result of the infiltration
of the blood  into the substance of the brain.
  The size  of the cavity varies from that
of a pea  to one  capable of holding sev-
eral  ounces of blood, and occupies near-
ly the  whole of one of the hemispheres.
When of considerable magnitude, it very
generally ^communicates,  by a  rupture
through the intervening medullary mat-
ter, either with the surface of the brain,
the blood escaping into the cellular tissue
beneath the  arachnoid membrane, or with
the  ventricles.   Frequently the  septum
lucidum  is  torn,  and  both the lateral
ventricles become filled with blood;  in
some instances, the fornix, also, is torn;
and occasionally,  the apoplectic  cavern
and the lateral ventricles form but a sin-
gle  cavity.   Most  commonly,  the thin
membrane which closes the fourth ventri-
cle is ruptured, and the more fluid part of
the  blood finds its way  into the  cellular
tissue  beneath  the arachnoid  of the spi-
nal marrow as well as of the brain ; occa-
sionally, the arachnoid itself is  torn and
becomes infiltrated with  blood.  (Cruveil-
hier.)
   If the patient be  not  immediately  de-
stroyed by the apoplectic  attack, the  ex-
travasated blood coagulates;  the  serous
portion infiltrating into the cellular tissue
of the brain.  This infiltration takes place
almost  immediately, when the apoplectic
cavern  communicates with the surface of
the brain or with the ventricles; it takes
place more slowly when the  parietes of
the cavern preserve their integrity. The
infiltration into the substance of the brain,
communicates to  the medullary  matter
surrounding the extravasated blood a yel-
lowish  colour, which  becomes  gradually
fainter  in the  parts  of  the brain more
removed from  the latter.  This  colour is
generally perceived upon the third day of
the  attack, and is at its height by the
eighth  or eleventh; when absorption of
the  effused blood takes  place with the
greatest activity, and it is nearly deprived
of all  its serous portion.  A short time
afterwards, the  yellow colour disappears;
the coagulum of blood  is  reduced to a very
hard and black nodule ;  is rapidly dimin-
ished in size, and finally  completely  ab-
sorbed.  (Cruveilhier.)
   While these changes are effected in the
extravasated blood, the  inner  surface of
the  cavity in which it  is contained be-
comes smoother and more even; the cavi-
ty itself contracts in size, assumes more
of a spheroid form,  its  parietes become
covered with  numerous  minute vessels,
and  it is soon discovered to be lined by a
cellular structure,  sometimes  very deli-
cate, and at  others  very dense, and as it
were fibrous.   As the  coagulum of blood
becomes daily lessened by absorption, the
cavity diminishes still further in size, until
at length its  parietes  touch, and become
firmly adherent to each  other.   In other
cases, the coagulum becomes inclosed in
a perfect cyst lined with a serous mem-
brane ofa yellowish colour, which exhales
and  absorbs as other tissues of the same
class.  The parieties in these cases never
unite.  These  cysts were pointed out long
since by Brunner, by Bonetus, and Mor-
gagni ;  but it is to Riobe that  we are in- 
APOPLEXY.  (Anatomical Lesions.)                  213
debted for a correct description of, and just
views in regard  to  them._  He believes
that the serous fluid exhaled by the lining
membrane of the cyst, is useful by bathing
and dissolving the contained coagulum of
blood, and thus facilitating its absorption.
(Sur rApoplexie.  Paris, 1813.)
  The absorption of the effused blood and
the perfect cicatrization  of the  lacerated
portions of the brain, in cases of apoplexy
from which the patients  have eventually
recovered, is proved by  the observations
of  numerous physicians, more especially
by  those of Rochoux, Riobe, Bricheteau,
and Serres.   Sometimes, when the apo-
plectic cavern has been small, the cicatrix
is in the form of  a hard  knot of a fibrous
consistence, which forms  a strong contrast
with the softness of  the parts by which it
is surrounded. According to Cruveilhier,
this is the most frequent  form of the cica-
trix :  sometimes,  however, the latter has a
linear appearance, as was first observed by
Serres; this kind of  cicatrix is the most
rare.  Whenever, either from the large size
of  the cavity, or from any other cause, the
immediate contact of  its parietes cannot
take place, the latter cicatrize  separately,
and constitute a  kind  of ventricle within
the substance of the  brain.  Most gene-
rally, the  parietes  are  attached to each
other by a loose  cellular tissue; in other
cases, as already remarked, a cyst is form-
ed, lined with a  serous membrane.   The
substance  of the brain  surrounding  the
cicatrix has either its  natural consistence,
or  it is  considerably increased  in density
for the thickness of one or two lines, or even
more.   Cicatrices are found in the brains
of  all  subjects who  during their life-time
have  been affected  with paralysis conse-
quent upon an attack of apoplexy, at what-
ever period death may  have occurred.  And
their number always corresponds with the
number of attacks.  (Rochoux.)
   The complete  absorption of the effused
blood is  generally effected, and the cica-
trization of the cavity containing it com-
pleted, according to Cruveilhier, by the
end of the fourth or fifth  month from  the
apoplectic attack. Riobe, however, found
blood in the cavity twenty months after
the apoplexy had occurred;  Moulin, at
the end  of a year,  and  Serres, at  the
termination of even two and three years.
   In certain cases of apoplexy, the extra-
vasated blood, instead  of being contained
in a cavity formed by a rupture of the sub-
stance of the brain, is infiltrated into the
latter, and is said to  be combined with
the medullary matter, which is in a state
of disorganization. This peculiar condition
of the brain,  which Cruveilhier denomi-
nates capillary apoplexy or apoplectic soft-
ening, and considers to be identical with
the red softening of the brain, so accurate-
ly described by Lallemand and Rostan,
is evidently  owing to the  effused blood
being collected in numerous minute cavi-
ties or foci.   An example in proof of this,
was recently presented to the Anatomical
Society of Paris, by M. Tersier.  (Arch.
Gen. Jul. 1834.)  The substance of the
brain, to  a certain extent,  is reduced  to
a kind of pulp, and varies in colour, ac-
cording to the quantity of blood  effused,
from a  light rose to a deep red, purple,
or  even  black.   In some cases,  the soft-
ened portion of  the brain is not strictly
circumscribed ;  but  in others,  it  is  so
much so, that it appears to be contained  in
a cavity  formed in the cerebral substance,
from which it may be entirely removed,
leaving the parietes clean. Small coagula
of blood are  sometimes found in the midst
of the softened portion.  The gray sub-
stance  of the  brain  is the  part  most
commonly affected with this  species  of
softening, and particularly that of the con-
volutions. The  forty-six  cases  reported
by  Lallemand,  in  his  two first letters,
(Recherches anatomico-pathologique), pre-
sent sixteen  examples of softening of the
gray matter  of the convolutions;  thirteen
of the gray  matter of the corpora striata
and thalami; four of the tuber annulare,
 eight of the  medullary mater, and five in
 which both portions of the brain were near-
 ly equally affected.
    In a paper read before the Royal Acade-
 my of Medicine of Paris, in the year 1829,
 M. Tonnele has pointed out the connexion
 which exists between many of the morbid
 conditions of the  brain, discovered in those
 who die of apoplexy, and an inflammation
of the sinuses of the dura mater.  Thus,
 while the cavities of the latter, and of the
 superior  cerebral veins, contained bloody
 concretions,  and false membranes, some-
 times  mixed with  pus,  in every instance
 there was an injected state of the vessels
of the pia mater; in many, infiltrations  of
 blood  beneath  the  arachnoid,  extensive
 extravasation of blood  upon the surface  of
 the brain, with softening of the latter.   In
some cases, apoplectic cavities existed  in
the centre of the hemispheres; and  in
others, the gaping orifices of ruptured veins
 were very perceptible.
   4. Serous effusion.  Effusion of serum
into the ventricles, and beneath the mem-
branes of the brain, is frequently met with
in apoplectic subjects; but, almost inva-
riably, it is  found  to  be connected with
extensive congestion of the  cerebral ves-
sels ; with inflammation, or other diseased 
214
APOPLEXY. {Anatomical Xjesions.)
conditions of the membranes of the brain,
or with extravasations of blood into the
latter.  In the majority of cases, therefore,
the effusion of serum, found in the brain,
after death from apoplexy, cannot  be con-
sidered as a  primary disease;  nor is it
probable that its accumulation  can take
place with such rapidity as to produce the
symptoms of an apoplectic attack.  The
quantity of fluid effused often  bears  no
proportion to the degree of the apoplectic
symptoms.   We find it in small quantity,
even when the latter have been strongly
marked and long continued;  it  exists
in  large  quantity, when the symptoms
have been slight; and finally, we see most
extensive effusion in the brain, where there
have been no symptoms of apoplexy what-
ever.   The direct  inference  from these
facts is, that in the cases of apoplexy with
effusion, the  presence of the  fluid cannot
be considered as the  cause of the apoplec-
tic  attack.  (Abercrombie.)   There can
be no doubt, however, that in certain cases,
a state of coma, simulating apoplexy, does
result from the general pressure to which
the brain is  subjected, from a very large
accumulation of serum between its mem-
branes, or within its  ventricles.  Effusion
of serum in the brain is  unquestionably a
frequent consequence upon apoplexy, and
is often the cause to which  the  sudden
death of the patient is to  be attributed.
(Cruveilhier.)   The number of apoplec-
tics who die from effusion of serum within
the cranium, equals,  at least, according to
the observations of Rochoux, the number
of those who perish  from the immediate
effects of the cerebral hemorrhage.
  5. A diseased condition of the mem-
branes of the brain;  or of the latter, with
or without effusion of blood, or of serum.
In nearly all the cases of what Serres
denominates meningeal apoplexy, (in other
words, apoplexy  without paralysis,)  the
membranes of the brain presented, on dis-
section, more or less ofa diseased condition.
When no effusion had taken place, this
gentleman  found the pia  mater thickened
and dry, the vessels somewhat distend-
ed, and  the  dura   mater  thickened  in
many  places.  The  tunica  arachnoides
was opaque; and where  it lines the ven-
tricles, covered with  whitish granulations,
of an extraordinary form.   In  cases where
serous  effusion existed, the vessels of the
meninges were found distended; the whole
of the pia mater covered with  a lace-work
of innumerable small vessels;  the arach-
noid very opaque, thickened, and covered
in certain places with a whitish exudation,
particularly conspicuous along the princi-
pal venous trunks, over which  it  formed a
kind of veil.  The opacity and thickness
of this tunic were much more considerable
at the base of the  encephalon, about the
pineal gland,  and  in  the ventricles, than
elsewhere.  The plexus choroides was al-
most  invariably altered from its  natural
texture ; being distended, and presenting
transparent cysts, filled with a  pellucid
(sometimes yellowish) fluid, slightly saltish
to the taste.  At other times, this fluid was
sanguineous or sero-sanguineous; more
rarely, little clots of  blood were found in
the interior of the cysts.  The size of the
latter varies much.  Serres has seen them
as large as a small musket-ball. When san-
guineous or sero-sanguineous effusions ex-
isted  in the  brain,  besides the  morbid
condition of the pia mater described above,
the  arachnoid  was  evidently  inflamed
and red, without  its vessels being very
distinct.  This appearance was peculiarly
striking in the ventricles, which  seemed
to be the principal seat of irritation. (An-
nuaire Med. Chirurg. I.)
   The substance of the brain in apoplec-
tics  is  frequently  found  softened.  The
red softening of Lallemand, from infiltra-
tion of blood, we have already referred to:
the white and purulent  softenings of Cru-
veilhier  are  less frequently met with.
In one case, reported by Morgagni, (Epist.
V. 4.), a great quantity of pus was found
in the left lateral ventricle, without any
other lesion of the  brain.   Lapeuronie
relates a curious case, occurring in a per-
son with fracture  of  the skull, in which
suppuration taking place within the cra-
nium, the patient  became  completely co-
matose every  time the pus was  allowed
to accumulate upon  the  surface of the
brain.  (Gama.)  The  symptoms, however,
which are  commonly produced by soften-
ing and suppuration of  the brain, can
scarcely be considered  as  identical  with
those of apoplexy.
   Tumours, developed in the central parts
of the  brain,  are  occasionally observed
after an apoplectic attack.  We have our-
selves met  with a large  tumour in  the
anterior part  of one  of the  lobes of the
cerebellum. Similar tumours are also no-
ticed by various authors.  Frequently the
encephaloid tumour  contains within  its
centre a large coagulum of blood, and is
surrounded with small cavities containing
blood, in the midst of a tissue very anala-
gous to that of the brain. (Cruveilhier.)
   A diseased  condition of the  blood-ves-
sels  is very commonly observed  in  the
brains of  subjects in whom death  has
resulted from  apoplexy.  There is some-
times ossification of the arteries, and in
other cases that peculiar earthy brittleness 
APOPLEXY.  (Pathology.)                      215
to which Scarpa has ascribed the produc-
tion of aneurism.   And the canal of the
artery will be found, in many places, to be
considerably contracted at the  hardened
parts; sometimes entirely obliterated.  In
other rare cases, numerous branchesof the
principal arteries of the brain will be found
to present a succession of  small  opaque
osseous rings, separated from each other
by small portions  of  the artery, in its
healthy  state.  This is  a very common
occurrence in the brains of elderly persons.
In some cases, again, the inner coat of the
artery is much thickened, of a soft pulpy
consistence,  and very  easily  separated;
so that  when a  portion  of  the artery  is
compressed between the fingers, a  con-
siderable quantity of this  pulpy matter  is
forced out. (Abercrombie.)
   The sinuses of the dura mater are often
found diseased; their coats being thickened
and indurated, and  their canals obstructed
or obliterated.  When this is the case, the
veins running into the sinuses are gene-
rally enlarged,  tortuous, engorged, and
apparently varicose.
   After a single or  frequent  attacks of
palsy, especially when  the patient has
survived for a considerable time, with per-
sistent paralysis,  and a decided feebleness
of the intellectual faculties, after death, it
is often found that an atrophy of the cere-
bral convolutions has  taken place.   The
brain no longer fills the cavity of the cra-
nium, but the vacancy is supplied by an
effusion of serum into the sub-arachnoidean
cellular tissue.   Frequently the atrophy
occurs in the whole of the hemisphere in
which extravasation had taken place; more
frequently, in the corpora striata and thala-
mi optici. (Cruveilhier.)
   Pathology.  The peculiar character of
the  phenomena essential to apoplexy, a
sudden suspension, namely, of the functions
of sensation, consciousness, and voluntary
motion, as well as of the intellectual facul-
ties, indicates, very clearly, the depend-
ence of the disease upon a morbid condition
of some  portion  of the brain.   On  this
point, nearly all medical authorities, even
from  the earliest periods of our science,
are in accordance.   In regard, however,
to the exact nature of the lesions of the
brain, by which the apoplectic symptoms
are  produced, a  very great diversity of
opinion has always existed.   And even at
the present day, notwithstanding the im-
portant  discoveries  that have been made,
in regard to the structure and functions of
the nervous system, and  the very great
industry with  which its morbid anatomy
has been investigated, the condition of the
brain, in  apoplexy,  remains, as much as-
ever, a subject of dispute.  While we ad-
mit the difficulties with which the inquiry
is, to a certain extent, surrounded, we
are nevertheless persuaded, that a careful
examination of all  the facts  connected
with the  disease,  will  lead us very rea-
dily to correct views  in regard  to  its
pathology.
  A suspension or abolition of the  senso-
rial  functions of the brain, is a pheno-
menon which occurs under very different
circumstances. Sometimes, it takes place
suddenly, in  persons  apparently in the
most perfect health; while in other cases,
it is preceded, for a longer or shorter pe-
riod, by a deranged state of the functions
of the brain,  attributable to either acute
or  chronic  inflammation  of  the  organ.
Hence, Lallemand, Bouillaud, Ducrot,
Cruveilhier, and some other pathologists
of equal eminence, have, for the sake of
perspicuity, restricted the term apoplexy,
to a sudden paralysis,  general or partial,
of the sensitive,  locomotive, and intellec-
tual functions. It cannot be too frequently
repeated, remarks Cruveilhier, that the
sudden occurrence of the symptoms is an
essential  character  of apoplexy.  The
judge upon the bench, the orator in the
tribune, the traveller in his carriage or on
horseback, as well  as the  individual qui-
etly seated  at table, walking,  conversing,
or  even wrapped  in  the  most  peaceful
slumbers, and while,  apparently, in the
fullest enjoyment of health, is struck with
the  disease,  as by a  flash of lightning.
Other pathologists again, extend the term
apoplexy  to all cases in which sense and
motion become suspended or destroyed,
either partially or entirely, provided this
has  not  been preceded,  for  any great
length of time, by very  decided symptoms
of cerebral disease.  Taking,  however,
those cases  to which the term apoplexy is
most commonly applied, by a close atten-
tion to their symptoms it will be found
that they  differ from each other in certain
important particulars:  thus, in some in-
stances, the patient  is  suddenly and com-
pletely deprived of sense and motion, from
which state of deep stupor he cannot be
roused by the application of the most pow-
erful stimuli, but, in a very short time, ex-
pires.  In other cases,  he experiences a
suspension,  more or less sudden and com-
plete, of sensation and of motion; in other
words, falls  suddenly into a state of coma
resembling  deep  sleep; his features are
not,  however, distorted by'any unnatural
contraction of the muscles  of the mouth;
the  respiratory action  is equal on both
sides of the thorax, and  the limbs, on both
sides of the body, are, to a certain extent, 
216
APOPLEXY.  (Pathology.)
excitable, when a proper stimulus is ap-
plied to them;  or, if the  stupor be not so
complete, but  that  the patient may be
roused from it momentarily, so as to un-
derstand words addressed to him in a loud
tone of voice, he will present either hand
or leg, on being asked  so to do;  thus indi-
cating, that notwithstanding the torpor of
the brain, the nervous and muscular power
is equal on both sides of the body, and is
benumbed, but not destroyed.  If the pa-
tient recover from the  attack, he regains,
at  once,  the  entire command  of all his
voluntary muscles, and,  in general, the
functions of the brain quickly resume the
same state of vigour they possessed previ-
ously to the occurrence of the disease. In
a third class of cases, besides the state of
deep stupor observed in the last, there is
also a complete destruction of sensation
and of motion in certain of the  voluntary
muscles, generally those of one entire side
of the body.  No stimuli that can be ap-
plied, will excite in them the least feeling
or contraction.  The patient generally lies
upon the  side  thus paralyzed,  and the
muscles of the face, especially those of the
mouth,  are drawn in  the  opposite direc-
tion.  Although  the profound stupor, in
which the patient is,  in  general, at first
plunged, may render the exact  condition
of the two  sides of the body, somewhat
equivocal, yet the distortion of the mouth
is rarely, if ever, absent.   Should the pa-
tient recover from the state of  coma, the
muscles on one  side of the body will still
remain paralyzed.  The  paralysis  may,
however, disappear in the course of time,
but most commonly it is permanent.
   In those  cases, therefore, of  apoplexy,
not immediately fatal,  we distinguish two
very distinct forms of the disease;  the one
accompanied with simply a comatose con-
dition  of the brain;  the other, with coma
and a  complete  destruction of  the  influ-
ence of the brain over  certain parts of the
body:  in other words, apoplexy  without
paralysis,  and apoplexy  with  paralysis.
Most usually the attack commences with
coma, but in many instances, the paralysis
is the phenomenon first observed; in some,
it is unattended  with  stupor throughout.
The consideration of these latter cases be-
longs properly to the subject of palsy.
   Passing by, for the  present, the consi-
deration of the cases  of apoplexy which
terminate almost immediately in death; a
very important inquiry presents itself in
relation  to  the two  forms of the disease
marked by the absence or presence of pa-
ralysis ;  whether, namely, this difference
in the phenomena by which the apoplectic
attack is accompanied, can be  traced to
different morbid  conditions of the ence-
phalon.  It is to Serres, that we are in-
debted for the satisfactory investigation of
this  question.  Of one hundred cases of
apoplexy which he  studied with  the ut-
most care,  from the  first onset of the at-
tack  until its termination  in death, he
found  that twenty-one were  unattended
with paralysis,  while  seventy-nine  pre-
sented a complete loss of motion of one or
both sides of the body.  On examining, by
dissection,' the contents of the cranium in
the whole  of these  cases, he found inva-
riably, that in those  in which  paralysis of
the muscles was  absent, the substance of
the brain presented no trace of disease,
while in the  cases in which paralysis ex-
isted, certain portions  of that organ were
in a morbid  condition—in other words,
disorganized. From these and numerous
similar facts, he was led to the follow ing
conclusions, namely; 1st.  when the  apo-
plectic attack presents  no symptoms of
paralysis, we may presume that the  dis-
ease is seated in the meninges, and  that
the substance of the brain is neither dila-
cerated  nor  otherwise  altered from its
healthy condition: 2d. when, on the  con-
trary, the apoplectic attack is  attended by
paralysis, it is the brain itself which is the
principal seat of the disease.
  Having, therefore, determined two im-
portant facts in relation to the pathology
of apoplexy,  first, that the sensorial func-
tions of the brain may be suspended for a
time,  or  completely  destroyed, without
any  morbid change in the texture of the
organ, and second, that persistent paraly-
sis is very  generally, perhaps always,  pro-
duced by a disorganization, to a greater
or less extent, of a part of the substance
of the brain ; let us  now examine into the
nature of those changes in the membranes
and  in the  brain itself, by which the  two
phenomena,  coma and  paralysis, are  pro-
duced.   Recurring to the dissections of
Serres,  which are,  in fact, the  only ones
from which any decided conclusions  can
be drawn,  as in  them  alone  the appear-
ances detected after death have been ac-
curately  compared  with the  symptoms
during life, we find, that of the twenty-
one subjects  who died  of simple apoplexy
—that is,  unattended  with palsy, in  six-
teen cases, where the disease had conti-
nued for a length of time, the pia mater
was injected with blood, its vessels were
much  distended,  and the tunica arach-
noidea was opaque and thickened.   In all,
there was considerable effusion of serum,
either into the ventricles, or upon the  con- 
APOPLEXY.  (Pathology.)
217
 volutions of the cerebrum.   In one case,
 the arachnoid was red in the interior of
 the left ventricle,  slightly opaque in the
 rest of its expansion, with numerous mili-
 ary granulations scattered  over its sur-
 face.   The  left lateral ventricle was the
 seat of a sero-sanguineous  effusion.  In
 two cases, the arachnoid  was sensibly
 inflamed, and a sero-sanguineous effusion
 existed upon the surface of the  hemi-
 spheres.  In  the  two  remaining  cases,
 there was no effusion of blood or serum,
 but the  arachnoid  had  a dry and  some-
 what  thickened appearance, with  mem-
 braniform exudations.  In some cases  of
 simple apoplexy,  Serres has  found the
 arteries  upon the  surface of the brain to
 be greatly  distended, and  one or more
 ruptured, giving rise  to  an  extravasation
 of blood upon the convolutions,—in others,
 the extravasation was traceable to a rup-
 ture of the  veins.  A  great  number  of
 cases  of simple apoplexy, examined sub-
 sequently,  have confirmed  the general
 conclusions and facts stated  above.
   In regard to the condition of the brain
 in subjects who die of  apoplexy with pa-
 ralysis, of one hundred and seventy-one
 cases  dissected by Serres, with the  ut-
 most  care,  the texture of  the brain, in
 every  instance, was found to be more or
 less disorganized.  Excavations of different
 6izes  existed, generally  in the  substance
 of the cerebrum,  but occasionally in the
 cerebellum or medulla oblongata.  These
 excavations were  filled with blood, vary-
 ing in appearance, according to the time
 which had elapsed between its extravasa-
 tion and the death of the patient—while
 the portions of the brain immediately sur-
 rounding the effused blood, were red, soft-
 ened, yellowish, hardened, and otherwise
 diseased, according to the length of time
 intervening between  the attack and the
 extinction of life.   These observations of
 Serres, in relation  to the disorganized
 state of portions of the brain, in cases of
 apoplexy with paralysis, are confirmed  by
 the investigations  of Rochoux, Riobe,
 Lallemand, and Cruveilhier, as will be
 seen by referring back to our general ac-
 count of the post-mortem appearances pe-
 culiar  to apoplexy.
   We find  then,  from  the  repeated and
 cautious dissections of Serres and others,
 that in cases of apoplexy unattended with
 paralysis, if we except the serous and san-
guineous  effusions, the only morbid ap-
pearances detected after death  are  con-
fined entirely to the meninges of the brain.
The diseased condition of the membranes
in these  cases,  Serres refers, and we
  vol.  ii.           19
 think with great propriety, to the effects
 of preceding irritation or inflammation;
 and as a constant correspondence  existed
 between the alteration of structure in the
 two inner tunics of the brain and the effu-
 sion by which it was accompanied,  this
 affords, he conceives, sufficient presump-
 tive proof that  they are connected  to-
 gether as cause and effect; and the effused
 fluids, whether blood, serum, or both, are
 pronounced  by  him  to  be  of no  conse-
 quence, whatever, in the production of the
 apoplectic symptoms.
   That in  a large number, perhaps in all
 of the active forms of apoplexy, the pro-
 duction of the disease is intimately depen-
 dent upon an irritation occurring in the
 brain, either  primarily or transmitted to it
 from some other  organ, is proved by so
 many and such striking facts, that we can
 have no hesitation in giving our full assent
 to the proposition.  But we cannot admit,
 that irritation or  inflammation simply of
 the  membranes of the brain will explain
 the  production of any of the symptoms
 which ordinarily characterize the apopletic
 attack.   A suspension or interruption of
 the functions of the brain, occurring more
 or less suddenly, constitutes the very es-
 sence of the disease in all its forms. Now,
 that this suspension of its functions can
 occur without any change from the healthy
 condition  of the  brain itself, no one, we
 presume, will contend.  Inflammation of
 the pia mater or arachnoid membrane, or,
 more strictly speaking perhaps, of the su-
 perficies of the brain, will unquestionably
 produce a state of coma; seldom, however,
 in its  first stage, or until the period  of
 excitement has terminated.  But then the
 stupor is attended, and has been preceded
 by phenomena which will remove it from
 out the class of apoplexies strictly so call-
 ed.  In the  numerous and diversified ex-
 periments of Rolando on the brains of
 living animals, we find  that stupor and
 apoplexy were invariably produced, not,
 as Serres has maintained, by an irritation
 merely of the membranes, but of the sub-
 stance of the encephalon.  Simple  irrita-
 tion, amounting  to  inflammation of  the
 membranes,  was  attended neither by  a
 suspension or interruption of sensation,
 nor of motion in any part of  the animal's
 body.  (Saggio  Sopra la verra struttura
 del Cervello.)  Irritation or inflammation
 of the meninges of the brain can, in fact,
 give rise to a complete attack of apoplexy
 in one of three ways only: either by the
 congestion which it produces in the super-
 ficial vessels of the cerebrum ; by an effu-
sion of serum, blood, or other fluid, into the 
218
APOPLEXY.
(Pathology.)
ventricles, or upon the convolutions; or by
disorganizing to a certain extent the gray
matter of the surface of the brain.   The
last of course, did not occur in the cases
examined by Serres, the substance of the
brain  being invariably found free  from
disease; but it has been observed by other
pathologists.   In all  the  examinations,
however, of Serres, congestion of the ves-
sels of the  brain  and its membranes evi-
dently did exist;  and with the exception
of two cases, this congestion was accom-
panied with an extensive serous, sanguine-
ous, or sero-sanguineous effusion, either
upon the surface  of  the brain, or into the
ventricles:  and it is to the pressure exert-
ed  upon  the brain by this congestion and
effusion,  in  connexion with the irritated
state of the organ, that we are inclined to
refer the comatose symptoms of the disease.
This leads to the important and much dis-
puted  question, will  pressure  upon  the
brain from congestion of its vessels or from
effused fluids, produce a suspension  of its
sensorial  functions]   Abercromeie (Dis-
eases of the Brain and Spinal Cord) de-
nies explicitly that apoplexy ever depends
upon pressure of any part of the encepha-
lon, and the same assertion is repeated by
Copland and  Clutterbuck.   All  these
gentlemen  assume it as a fact, that the
brain  is incompressible, and consequently
they infer that  it  cannot suffer from pres-
sure.   Whether the texture of the brain
be or be not compressible, it is not neces-
sary for us  at  present  to inquire: that it
is liable to pressure, and that its functions
will in that manner be impeded, can be
clearly established.  Nature, indeed, ap-
pears  to  have been  extremely  careful to
guard  the brain from the least  degree of
pressure, by inclosing it in the scull, and
by the peculiar arrangement of the dura
mater, and of the venous sinuses within
the cranium; and from this very circum-
stance we  should be led to infer that a
very slight  pressure would be injurious.
Even  Dr. Abercrombie admits  that  the
brain may suffer from  pressure, almost in
the very  sentence in which he denies it:
thus, he refers the production of apoplexy
to such a derangement of the circulation
in the  vessels of the head, that more blood
enters  by the arteries, than can be trans-
mitted by the  veins.   Now, as the brain
completely fills the cavity of the cranium,
it  is impossible for it to escape pressure,
when  a  greater  amount of blood enters
into its arteries than can be removed  by
the veins.  When slow serous effusion in
the ventricles  gradually distends  these
cavities to an immense size, and frequent-
ly reduces the hemispheres of the brain to
a mere shell, of which there are so many
instances on record, is it not evident that
the absorption of the  cerebral mass must
have been produced by the pressure exer-
cised upon it by the effused fluid ]  (John-
son.)   In proof of the fact we have  as-
sumed, that, namely, a state of coma may
be caused by pressure upon the brain and
cease the moment that pressure is abated
or withdrawn, numerous  cases  might  be
cited.  We  condense  the following from
the works of Abernethy, (II. 26.).  A
boy, fourteen years  of age, fell from a
height, upon his head.  When brought to
the hospital, he appeared to be almost  in
a dying state.  The anterior inferior angle
of the parietal and  part of the frontal
bones were  found to be  depressed.   A
piece  of the  cranium  being removed  by
the trephine, a large  quantity of coagu-
lated blood was found  beneath; another
perforation was then  made, and the sur-
geon, gently removing  a portion of the
cranium, introduced  his  finger into the
aperture as far as the  second joint, before
he touched the dura mater.  A third piece
of bone being  removed,  four  ounces  of
coagulated blood were taken away, upon
which, the dura mater quickly rose  to  its
proper  level.  The lad, who, at the begin-
ning of the operation,  lay quite  insensible,
with a feeble, intermittent pulse, and labo-
rious, interrupted respiration, became rest-
less, and expressed a sense of pain, towards
its termination, and soon replied to vari-
ous questions addressed to him.  In a se-
cond case, a man, who was knocked down
by a brick-bat thrown at him, was imme-
diately brought to the hospital, in a state
of profound apoplexy.   The right side  of
the frontal bone, and lower part of the pa-
rietal, were beaten in.  By three perfora-
tions of the  skull, the depressed portion
of bone was  removed; a quantity of co-
agulated blood  lay upon the orbitary pro-
cesses  of the frontal  bone, and when a
large handful was removed, it was  found
to have so pressed back the anterior lobe
of the brain, that the  surgeon could touch
with his finger the transverse spinous pro-
cess of the  sphenoid  bone.  The brain,
after the blood was removed, rose slowly,
and the man began to show signs of  re-
turning sense.  He was bled, and his bow-
els were emptied by a purge.  The next
day he was so far  recovered as to give  an
imperfect account of the accident.  Mr.
Hill, of Dumfries, also relates a case, in
which  the artery of the dura mater was
ruptured,  without  either  fracture  or de-
pression of the skull.  Four days after the 
                          APOPLEXY.

accident two portions of bone were re-
moved by  the  trephine, and  so  large  a
coagulum of blood was  found  lying upon
the dura mater, as to make him fearful of
removing all of it at once;  but, on taking
out a few ounces of it the patient, who
had heretofore lain in a state of apoplexy,
looked up, on his being spoken to,  like one
awakened from sleep—knew  and named
every body, and raised the arm of the op-
posite side, which had been paralytic  from
the time of the  accident.   In the cases
of apoplexy recorded by Drs. Bang  and
Watts,  referred to in a former part of
this article, the disease was evidently pro-
duced by pressure exerted  upon the brain
by  blood effused between  the skull  and
dura  mater; and in the curious case re-
ported by Lapeyroine, coma was induced
every time a collection of pus was allowed
to take place within the skull, and imme-
diately ceased when the pus was removed.
But we return to the question—will ex-
tensive engorgement of the vessels of the
brain produce such a degree  of pressure
upon any part of the organ, as to occasion
a suspension of its functions 1  Many cases
of simple apoplexy occur, in which,  after
death, no other morbid alteration is  pre-
sented by the brain excepting  an over-dis-
tended state of its vessels.   Two striking
instances of this are related,  the one by
Morgagni, the other by Fouquier.  In
the first, the whole  vascular system of the
brain was distended with fluid blood, in a
manner Morgagni  had  never before wit-
nessed.  Even some small vessels, which
usually are scarcely perceptible, were ex-
tremely large and turgid.  No other mor-
bid appearance was discoverable.  In the
second, the exterior vessels of the brain,
as well  as  those of the choroid  plexus,
were  unusually turgid,  and  numerous
points of blood were sprinkled  over all the
cut surfaces of the brain, the substance
of which was very firm.  The records of
morbid anatomy are replete with similar
facts; and  we have  ourselves met  with
them repeatedly, in dissections of apoplec-
tic subjects.  In such instances, Briche-
teau, who appears to have examined the
subject with the most attention, conceives
that the destruction of the  nervous influ-
ence  and of life, must  be  referred to the
general  compression  produced upon the
brain by the universal turgescence of its
vessels;  and nearly the same remark  is
made by Portal and others.   We  fully
accord with their conclusions.   From  a
congested state of the  cerebral  vessels,
remarks Gama,—who, it is proper to men-
tion, refers all  apoplexies to irritation of
(Pathology.)                       *l»

the brain,—an oppression of the nervous
mass, a suspension, more or less prolong-
ed, of the voluntary movements, and of the
perceptions,  may  unquestionably result;
but these phenomena are immediately dis-
sipated when artificial evacuations of blood
have been practised to a sufficient extent;
the regular  action of the vessels being
thus restored, they quickly empty them-
selves of the blood by which they are dis-
tended.  When,  however,  the state  of
engorgement continues too long, or is con-
stantly augmented by the continued deter-
mination of blood to the brain,  rupture of
the vessels or serous  extravasations  may
take place, which cannot be remedied with
the same facility.   The most fatal conse-
quences, from extensive lesion of the brain,
are then often experienced.  The  vessels
of the meninges participate frequently in
the engorgement  of those of  the brain;
either from the commencement, or subse-
quently.  It is  probable that  the mem-
branes may themselves be the seat, in
some cases, of irritation; but it is neither
to this complication, nor to the distension
of their vessels, that we should attribute
the comatose condition of the patient; for,
if the brain  be  not, at the same time, a
centre of fluxion, it would support, without
inconvenience, the mechanical effect of
the tumefaction of its envelopes.  In  some
cases, the cerebral congestion  is directed
towards the periphery of the organ; and
we have then a case of simple apoplexy,
with, probably, effusion.   More generally,
however, the congestion concentrates it-
self within its substance;  and then a rup-
ture or disorganization of  the  brain ordi-
narily takes  place, and we have apoplexy,
with paralysis.  It cannot, however, be too
frequently repeated, that the irritation of
the brain is the actual cause by which the
disease is produced, in all its forms.   All
sanguineous congestions are subjected to
the same laws.  Those which  succeed to
injuries of the head equally constitute real
apoplexies: the only peculiarity by which
they  are marked, relates  merely to the
mechanical cause by which the irritation
and congestion are produced.   (Plaies de
tete.  p. 230.)  It must be evident, that
many of those apoplexies, unattended with
paralysis, which occur suddenly, and are
almost as promptly removed by an appro-
priate treatment, are produced by pressure
upon the brain, from simple congestion of
its vessels.   In such cases, the quickness
with which the functions of the brain are
restored by a moderate loss of  blood, pre-
cludes the supposition of any considerable
morbid change  having occurred  in the 
220
APOPLEXY. (Pathology.)
membranes or substance  of the organ.
The rapidity with which congestions are
removed, in other parts of  the  body,  is
familiar to every  physician; and, that the
same prompt resolutions may take place  in
the congestions of the brain, can scarcely
admit of a doubt.  A  boy, mentioned  by
Zitzilius, had drawn his  neck-cloth re-
markably tight, and was whipping his top,
stooping and rising alternately; when, af-
ter a short time, he fell down apoplectic.
The neck-cloth  was now  removed, and
blood being drawn from the jugular vein,
he speedily recovered.  (Abercrombie.)
Cases of a somewhat similar character are
related by other  writers, and  one or two
have fallen  under our own observation.
   It is to  the oppression of the  brain,
resulting from congestive  irritation  of
an intermittent character,  that  we must
unquestionably refer those cases of apo-
plexy, the  attacks  of which assume  a
somewhat periodical character; occurring,
and sometimes spontaneously disappearing,
at tolerably regular intervals.   Cases  of
this kind have been observed by Wepffer,
Nyman,  Torti, Portal, and others; but
more especially,   by  Casimir Medicus.
Now, it  is impossible  to suppose, that in
such  forms of the  disease,  any serious
lesion  of the brain can give rise to the
successive attacks, and be promptly re-
moved in  the intervals.  It  is  far more
philosophical to refer their production to
what we know does occur frequently  in
other organs; a periodical irritation, name-
ly, with  congestion.   But,  if simple con-
gestion gives rise to the more favourable
forms of apoplexy, it appears capable, also,
of producing the  most violent and instan-
taneously fatal ones.  Dissection fully es-
tablishes this fact.  If a sudden and great
distension of the vessels of the brain takes
place, and the vessels are not speedily un-
loaded, either by artificial means,  or by
the rupture of their coats, or an exhala-
tion of blood or of serum, it  is very evident
that the whole  substance of the  brain
becoming oppressed, the functions of life
must consequently  be destroyed.   And
after death, the only morbid  appearance
presented by the  encephalon, will be,  in
such cases, an overloaded condition of its
blood-vessels. It is probable,  also, that to the
same cause, oppression, namely, of the sen-
sorium, from extensive congestion of its san-
guineous system, are to be attributed those
rare cases of apoplexy, in which death has
promptly followed the attack; and, upon
dissection,  no morbid  appearance what-
ever, it is stated, could be detected in the
brain or its membranes; the  turgescence
of the vessels having disappeared at, or
immmediately after death, as we find it to
do in other organs. (Brkheteau.)
  Two circumstances would appear to be
necessary, in order that  pressure of the
brain shall produce torpor of its functions:
the  first is, that it occur suddenly; and
the second, that its effects be experienced
by, at least, a considerable  portion of the
surface of the organ.  The brain  has the
power of adapting itself to a very con-
siderable  amount of pressure, when not
suddenly subjected to it.  Accumulations
of serum, and of blood, have slowly taken
place in the brain, to a very great extent,
and its functions have gone on, for a long
time, without, apparently, being the least
affected.  Even  when  the pressure has
been at first  such as to occasion some de-
gree of stupor, this has, in many instances,
disappeared  spontaneously, without any
diminution  in  the  degree  of  pressure.
Pressure  upon particular parts of the or-
gan, will also be borne with comparatively
little inconvenience.  When, however, the
whole or a large portion of the  superior
surface of the brain  is,  from any cause,
suddenly subjected to it, a  state  of coma
is almost invariably the  result   This is
proved by the case (by no means unique)
of the beggar, referred to by many physi-
ologists, whose  brain was  exposed  by a
perforation in the skull,  and  in whom a
state of drowsiness was induced when the
brain was pressed upon,  increasing  with
the degree of pressure, until at length the
man would become comatose.
  In some cases of apoplexy, the conges-
tion of the brain is so considerable, as to
produce a rupture of one  or more vessels
within the cranium; or the distended ves-
sels are relieved by a spontaneous hemor-
rhage, and the blood is poured out into the
ventricles, or over the surface of the cere-
brum.   If by this means the congestion is
removed,  and the extravasated blood is
small in quantity, the patient will recover
from  the  stupor into which he had  been
previously plunged, and in a short  time
will recover entirely his ordinary state of
health.  But  if the effused blood be in
considerable  amount, the  coma will  ordi-
narily become more intense;  and death,
almost immediate, may be the result  If,
remarks  Serues, referring  to  his  own
repeated dissections, the  irritation of the
membranes of the brain had been intense,
sudden, and of short duration; if the mem-
branes were inflamed, partially or  univer-
sally, the  fluid effused within the ventri-
cles, between  the convolutions, or in the
commencement  of the spinal  canal, was 
APOPLEXY.  (Pathology.)
221
sanguineous or  sero-sanguineous.  This
latter was so connected with the irritated
or inflamed condition of the membranes,
that if the  irritation or inflammation ex-
isted in one or both ventricles, the effusion
of blood was confined to that part.  If, on
the contrary, which more rarely occurred,
it existed only on  the  exterior of the en-
cephalon, the blood was found solely on the
surface of the brain: the ventricles were
empty, or the liquid which  they contained
was simply serum.  This  shows the inti-
mate connexion between the effusion, in
these cases, and the part of  the encephalon
which appeared to be the principal seat of
the congestion.  Cruveilhier has remark-
ed,  very  correctly,  that the  phenomena
of compression, those, namely, connected
with cases of stupor without paralysis, are
the only ones observable in those apoplex-
ies in  which the hemorrhage takes place
in the ventricles, or upon  the surface of
the brain, without rupture  or disorganiza-
tion of the latter ;  because,  in these cases,
the effused blood occupies a large surface,
and compresses,  pretty   uniformly,  the
whole mass of the brain—an opinion which
appears to be supported by facts, and by
the  observations,  generally speaking, of
other pathologists.
   Serous effusion, alone,  is but  seldom,
perhaps, a cause of the apoplectic attack.
It is doubtful whether the pressure  pro-
duced by an  accumulation of serum, can
ever take place with sufficient suddenness
to cause an immediate suspension of the
functions of the brain.  Extensive serous
effusion into the ventricles, or beneath the
membranes of the brain, will undoubtedly
produce a state of coma, more or less com-
plete ; but in such cases, the torpor of the
brain comes on slowly and gradually, with-
out  any thing like a sudden stroke or fit
and may be owing as much to the disor-
ganization of the brain as to mere pressure.
In nearly all the cases of apoplexy in which,
after death, serum is found in the brain,
other  morbid appaerances are  present,
fully sufficient  of themselves to account
for the production of the disease.  A state
of  congestion,  in  particular,  so often
present and upon which  the  apoplectic
attack so  frequently  depends,  has  been
shown, by  recent investigations, almost
invariably to give  rise to a  serous effusion,
often to a very considerable extent.
   The distinction  of apoplexies, by the
older writers, into serous and sanguineous,
is altogether unfounded.  Independently of
the  serous  effusion, when it does occur,
being  almost  invariably accompanied, as
we have just remarked, by an engorged
condition of the arteries or veins, and other
morbid states of the brain, or of its mem-
branes,—many of the cases which termi-
nate by a serous effusion, exhibit in their
early stages  all the  phenomena usually
assigned to sanguineous apoplexy, such as
flushed  countenance,  strong pulse, vigour
of constitution, &c, whilst, on the other
hand, many of those accompanied by pale-
ness  of countenance and  feebleness  of
pulse,  and occurring  in  debilitated  or
broken-down constitutions,  or in the aged,
commonly  referred to the class of serous
apoplexies, will be found, on dissection, to
be purely sanguineous.  Portal describes
a series of cases strikingly illustrative of
these facts.
  From the  foregoing remarks, it will bo
perceived that to oppression  of the brain,
from engorgement of the cerebral vessels,
especially  those of the meninges and su-
perficies of  the  organ, with or without
effusion between the membranes or into
the ventricles, we are inclined to attribute
in the  greater number of instances, the
production  of those  cases  of apoplexy
which are  unattended with paralysis; and
we  shall hereafter find that the comatose
symptoms  of nearly all attacks of the dis-
ease are referable to a similar cause. The
coma may, however, in some instances,
be dependent upon  a disorganization of
the  cortical substance of the convolutions
of the brain.   Bouillaud  has presented
some cases of this kind, but they are at-
tended, always, with peculiar phenomena
which  prevents their being strictly con-
sidered as  apoplexy.
   To what cause are we to attribute the
extensive  engorgement of the cerebral
vessels in certain apoplectic attacks ] The
common explanation, if explanation it can
be called,  of an increased determination
of blood to the head,  is inadmissible.   By
the  action of the heart alone, a greater
amount of blood cannot possibly be deter-
mined to one part of the body than to an-
other. We are not quite so positive, how-
ever, that apoplexy may not be sometimes
produced by the heart driving the blood
with such force into the  vessels  of the
brain, as to occasion  a rupture of one or
more of them, especially  when the brain
or its vessels are already in a diseased
state. This is probably the  mode in which
apoplexy is often produced  in subjects la-
bouring  under  hypertrophy of the  heart
and  in such cases as  the one reported by
Cruveilhier, in which a  contraction of
the aorta existed just  beyond the origin of
the  carotids, in consequence of which the
column of blood in the latter was driven 
222
APOPLEXY.  (Pathology.)
with greater force into the vessels of the
head than  under ordinary circumstances.
The blood-vessels of the  brain,  from the
relative delicacy of their coats and the
absence of that support which the vessels
of other parts of the body derive from the
surrounding cellular membrane, are  al-
ways peculiarly liable to rupture, and this
liability is increased in many instances by
a morbid state of their parietes.
  In the great majority of cases, it is to a
suddenly excited and intense irritation of
the brain or of its membranes,  that the
production of the congestion giving rise
to apoplexy,  is unquestionably to be re-
ferred.  Every organ,  when the seat of
irritation, becomes,  as is well known, a
centre of fluxion, and an increased amount
of blood  is determined to its vessels.  If
the irritation be suddenly carried  to its
highest degree,  the congestion  produced
is often  so great,  as to occasion  almost
immediately the  death or disorganization
of the  part in which it is seated.   That
apoplexy may very generally be  traced
to encephalic  irritation,  can scarcely be
doubted when we recollect that nearly all
its remote and  exciting  causes are pre-
cisely those which ordinarily give  rise to
inflammation of the brain; and,  more es-
pecially when we observe the attack so
often to be produced almost  immediately
upon the transfer of irritation  from the
stomach, the skin, or other remote organs,
to the brain;  and when, in addition to
these facts, we consider the morbid ap-
pearances brought  to light by dissection.
The symptoms  by which the apoplectic
seizure is so  often preceded, indicate a
state of more  or less cerebral  irritation
and an increased  determination of blood
to the vessels of the head. All the symp-
toms of apoplexy are also the ordinary re-
sults of well-marked inflammation of the
brain,  whenever the disease is not cut
short by appropriate remedies, or the death
of the  patient does  not occur during the
first periods of the disease or the stage of
excitement.  The only difference which
exists between ordinary apoplexy and that
which succeeds to acute  encephalic  in-
flammation, is  the  suddenness of  the at-
tack in the one  case, and its gradual ap-
proach, subsequent to the acute inflamma-
tory symptoms,  in the other.  To  these
facts may be added the very common oc-
currence of cerebral inflammation as a se-
quel to the apoplectic attack when this
has been but imperfectly  recovered  from,
or the patient at too early a period returns
to a stimulating diet and  his ordinary avo-
cations.  So striking is  indeed  the  rela-
tion  between apoplexy and inflammation
of the brain, that we are only surprised it
should have been so  long overlooked by
the majority of medical writers; more es-
pecially as  Stoll had already very ably
run the parallel between the two diseases.
  We maintain, then, that in all cases of
apoplexy marked simply by coma, and un-
preceded by symptoms of decided cerebral
inflammation, there takes place a  sudden
over-distension of the blood-vessels of the
brain, the result of preceding irritation of
that  organ.   Abercrombie, however, has
attempted to show that no more blood can
enter into the vessels of the brain at one
time than at another; in other words, that
the cerebral vessels  always contain the
same absolute amount of blood.  But the
records of morbid  anatomy prove  most
conclusively that the vessels  of the brain,
both arteries and veins, are often engorged
to a very great extent with blood, and that
not unfrequently, in addition to this en-
gorgement, sanguineous extravasation has
likewise taken place.   The arguments of
Dr. Abercrombie in  support of his posi-
tion  would be conclusive, we admit,  were
we to suppose the mass of the brain to
be perfectly incompressible—which, how-
ever, is not the fact.  Fully authenticated
cases are recorded, especially by the sur-
gical writers, in which the surface of the
brain has been found  so  much depressed
by blood extravasated beneath the skull,
as to leave a permanent depression,  capa-
ble of containing several ounces of blood;
in other instances, the depression has been
obliterated the moment the coagulum of
effused blood was removed. Now, we care
not how this is explained, whether by the
squeezing out of the fluids from the part,
or the closer approximation  of the mole-
cules of which the substance of the  brain
is composed—we merely adduce the facts
to prove that the mass of the organ is
compressible.   Indeed, were the  mass of
the brain absolutely incompressible, extra-
vasation of blood within the cranium  could
never  take  place, as the unyielding na-
ture of the  brain would  be an effectual
barrier to the escape of a single drop from
even a ruptured vessel  of considerable
size.  We should even be inclined to  adopt
the  opinion  of  Cruveilhier,  that the
brain, namely, is eminently compressible.
(Diet, de Mid. et de  Chirur.  Prat. III.
225.)  But  be  this as it  may, we know
that the brain, in common with the  other
organs of the body, may be the seat of irri-
tation, and that irritation when ofa certain
grade  will produce a congested state of
the vessels of the organ in which it occurs. 
APOPLEXY.  (Pathology.)
223
  That in many cases of apoplexy, an in-
creased amount of blood  is determined
to the vessels of the head, is proved by
the flushing  of the face, the  turgidity
of the features, the  increased  size and
throbbing  of  the  exterior  vessels of the
face and neck, which precede and accom-
pany the attack.  Numerous writers have
likewise remarked the unusual quantity
of blood which is discharged from the in-
teguments of the head, in the dissection
of subjects that have died during the apo-
plectic fit; in  some of Cheyne's dissec-
tions, upwards of a pound was discharged
in this manner.  When in addition to these
facts we find  that in the great majority of
cases the brain after death  from  apoplexy
does  present either extensive  engorge-
ment or at least a highly injected state of
its vessels, with often an extravasation of
blood from rupture or exhalation; taking
the whole in  connexion,  we have cer-
tainly  very solid  proof of unnatural dis-
tension of the vessels within the head, and
consequent pressure upon the brain.
  Dr.  Stokes, in  his  lectures  on apo-
plexy, confirms the accuracy of the fore-
going  views.   Presenting to his class  a
specimen  of apoplectic  effusion, "See,"
he  remarks,  "how extensively the sub-
stance of the brain has been torn,—the
cavity formed in this way is, you will per-
ceive, filled up with a large clot.   Now
there is one  consideration which strikes
us  at once, in looking at an effusion of
this kind into the substance of the  brain,
whatever  may be  its situation or extent
and this is, that the brain  must  be a very
compressible  organ.   Here  we  see the
brain torn, a cavity of large size formed,
and this completely filled with blood.  Now
it is obvious that the rest of the brain must
give way, in order to give room for the
formation  of  this cavity.   If, then, it be
true, that the brain is compressible,  so far
as to admit  of the formation of a  large
cavity, it necessarily follows that, contrary
to the opinion  of Drs. Abercrombie and
Clutterbuck, the quantity of blood  in the
brain may vary, and be at one  time greater
than at another. It may be argued against
this, that the  illustrative proof in this case
is derived from a pathological condition,
and  that  under such circumstances, the
brain has room  for the  formation of a ca-
vity, by the emptying of some of its ves-
sels.  Here,  it is  urged,  is a cavity, but
the emptying of the vessels  of  the brain
compensates  for  it; thus room  is found,
and there is  no increase in  the quantity
of blood circulating in the brain.  This,
however,  I look upon as a mere petitio
principii,  nor have  we  any  reason to
think, that, in a case of apoplectic effu-
sion, there is any corresponding emptying
of the vessels, for dissection almost always
shows a surcharged state of all the ves-
sels."  (Lond.  Med.  and  Surg.  Journ.
Sept. 1834.)
   All tissues, the vessels  of which are in
a state  of congestive irritation, are liable
to be the  seat  of a  spontaneous hemor-
rhage more  or less extensive; and  that
such is  precisely the case with  the tissues
of the brain in apoplexy, is, we conceive,
fully established by a careful examination
of the causes and  symptoms of the dis-
ease,  and a comparison of these with the
morbid appearances so frequently revealed
by dissection.  With Gama, therefore, we
embrace entirely the opinion of those phy-
sicians who consider apoplexy to be merely
a grade of encephalitis.  The slow or ra-
pid invasion  of the cerebral irritation, its
termination  in  a hemorrhagic action of
the vessels of the  affected  tissue, or its
regular march through the different pe-
riods  of inflammation to a complete disor-
ganization of a portion of the organ, con-
stitutes all the difference which exists be-
tween the phenomena of apoplexy, para-
lysis, or encephalitis and its various se-
quele.  These  facts have been very hap-
pily illustrated  by Lallemand,  Serres,
Gama,  and other later pathologists.  We
are not, however, prepared, let  it be un-
derstood, to deny that mechanical impedi-
ments to the return of the blood from the
head,  may  cause, under  certain circum-
stances, an  attack of apoplexy,  such as
ligatures about the neck, tumours pressing
upon the jugulars, disease of the lungs,
heart, and  large blood-vessels, &c.; but
even  in such cases, we maintain that con-
gestion of the cerebral  vessels and  con-
sequent oppression of the brain  do  take
place, and that in this manner the  pheno-
mena of the disease are produced.
   In  many cases of apoplexy, the first im-
pression of the exciting cause would ap-
pear to give rise to a decided sedation of
the brain and entire nervous system ; re-
action,  however, taking place,  congestion
and extravasation result. The appearance
•of the patient is, at first, somewhat simi-
lar to that of an individual in a state of
syncope.   His countenance is  pallid, his
eyes fixed and dim, respiration is slow and
scarcely audible, the pulse small, slow,
and  feeble;  the limbs are perfectly re-
laxed, and the  surface of the  body often
considerably below the natural tempera-
ture.   These symptoms  soon give place,
however,  to those which ordinarily ac- 
224
APOPLEXY.  (Pathology.)
company the apoplectic attack.  It is pro-
bable that in some instances the sedation
of the brain may be carried to such an ex-
tent as to produce immediate death, with-
out giving time for reaction to occur; in
this case, the brain will present upon dis-
section no traces of disease. A strong an-
alogy exists between the apoplectic cases
here  referred  to,  and the injury of the
brain resulting from concussion.   Thus,
the immediate  effects of the  injury may
be such as to produce instantaneous death;
but should this  not be the case, the brain
either resumes gradually its functions, and
the patient suffers no subsequent inconve-
nience,  or an irritation and congestion of
the cerebral vessels take  place,  and the
patient is rendered completely apoplectic.
In such cases, the  extravasation generally
occurs within  the same  portions of the
substance of the brain as in ordinary apo-
plexy with paralysis.
  The cases of apoplexy commencing as
we presume with decided sedation of the
sensorial and nervous functions, are most
commonly  those  produced by some sud-
den and violent  mental emotion.  Thus
persons have been struck almost instanta-
neously dead by a  sudden paroxysm of ex-
treme grief, fear, surprise, horror, joy, an-
ger, shame, &c., and after death the brain
has presented no traces of disease ;  but if
reaction come  on before the  patient ex-
pires, we have  then all the symptoms of
an  apoplectic attack;  and either conges-
tion or extravasation within the skull, with
or without disorganization of the brain, is
the post-mortem appearance observed. We
have had an opportunity of dissecting cases
of this character, in which death occurred
during the period  of what we presume to
be nervous sedation, and also, subsequently
to the occurrence of reaction; no morbid
appearance of  the brain in the one case
could be detected, in the other the state
of  that organ  was the  same as is most
usual after death from apoplexy.
   In the simple form of apoplexy, or that
unattended with paralysis, the congestion
of the brain is either resolved, and the pa-
tient promptly  recovers the entire use of
all his faculties,  or, in consequence of  a
large effusion  of blood within the ventri-
cles or upon the surface of the brain, the
recovery is more slowly effected, or the
torpor of the brain which is induced is so
great as to cause  a speedy extinction of
life.
  That the coma in apoplexy is invariably
the result  of the  oppression experienced
by the brain, either from congestion of its
vessels or from extensive extravasation of
blood upon  the convolutions  or into  its
ventricles, is proved, we conceive, by the
fact, that in cases of paralysis without stu-
por, the effusion of blood is generally small
in quantity and confined entirely to an ex-
cavation within the substance of the brain;
but when a  paralytic becomes suddenly
affected with all the symptoms of a com-
plete attack  of apoplexy, and dies, it will
then  be  found, pretty generally, either
that the vessels about the surface of the
brain are morbidly injected with blood, or
that the blood extravasated in the first in-
stance within the substance of the organ,
has burst through the surrounding portion
of medullary  matter,  into the ventricles
or upon the  surface  of the convolutions.
There are, however,  cases in which effu-
sion of blood upon the surface of the brain
will give rise to paralysis  and not to stu-
por;  in such  instances,  the  extravasated
blood is in considerable quantity and con-
fined to a  small space, thus producing only
partial pressure upon the cerebral mass.
When, however, the extravasation is very
extensive, both coma and paralysis may
occur simultaneously without  the  sub-
stance of the brain itself being injured.
Thus, in  extravasations of blood beneath
the  skull, from external violence, paraly-
sis of the opposite side to that on which
the blood  is  effused, often occurs, with or
without coma; but this would appear to
demand a much more extensive extrava-
sation than can be  supposed ordinarily to
occur in apoplexies strictly speaking. The
fact  however, is demonstrated by the fol-
lowing experiment performed by Cruveil-
hier : by means of a trephine, a portion
of the skull  of an animal being removed,
a number of thin lamine of horn were in-
serted between the bone  and  dura mater;
paralysis  was  produced  whenever the
compression  in this manner  was carried
to a  certain  extent.   It  may be objected
to this, that Serres,  in several instances,
laid bare, by  perforating the skull, the
longitudinal sinus, and piercing the latter,
immediately  closed  with  accuracy the
opening  in  the bone; and although the
dura mater became  covered  with a thin
layer of blood, no symptoms of either stu-
por or paralysis were produced. Cruveil-
hier repeated this experiment and with
the  same result; but he found that the
cavity of  the skull  is so completely filled
by the brain as to allow but a very small
amount of blood to escape from the sinus;
hence he concludes that this experiment
is inconclusive—and  he has shown that 
                           APOPLEXY.

the inference based  upon it is disproved
by  other  facts and  experiments. (Diet.
de Med. et de Chirur. Prat.  HI.  225.)
  According to the  facts collected  from
the  numerous  clinical  observations  of
Serres, it appears that the simple form
of apoplexy to which  our remarks  have
heretofore been principally directed, gene-
rally occurs before the fifteenth and  after
the sixtieth year, and more frequently in
females than in males.  Its  invasion  is al-
most always slow, and preceded by various
premonitory symptoms, of which the most
constant are, a general torpor of the  sys-
tem,  a disinclination to  mental exertion,
fatigue from the slightest exercise of the
intellect, obtuse perceptions, great inclina-
tion to sleep,  slowness of respiration and
of the circulation, diminished heat of the
surface, deficient secretion, derangement
of the digestive functions,  and occasion-
ally, nausea  and vomiting.   In many of
the cases observed by Serres, the disease
stole  on so  imperceptibly,  that  it  was
thought the patients were in a deep sleep,
when  in  reality they  were completely
apoplectic.  When,  however, the attack
succeeds to the suppression of some ha-
bitual drain from the system, or  of  cuta-
neous eruptions, or is brought on by a blow
or fall on the head, the invasion  is  more
sudden, and  the attack is generally pre-
ceded by a violent pain of the head.
   During the apoplectic state, the charac-
ter of the  pulse varies, according to the
age and strength of  the patient, but inva-
riably, the balance  between the  function
of respiration and that of  circulation  is
destroyed ;  the frequency  of the pulse
being contrasted with the slowness of the
respiratory movements.  In proportion as
this contrast is widened, the state of stu-
por and of coma is  evinced, and  its de-
gree is exactly proportioned to the differ-
ence which exists between  the two func-
tions.  The suspension of the senses gen-
erally occurs in the following order:  first,
that of touch; second, that of sight; third,
that of hearing; then embarrassment of the
tongue, and loss of speech;  then somno-
lency, and coma, accompanied with slow-
ness of respiration and activity of circu-
lation.  In proportion  as  the two latter
functions  recover their equilibrium,  the
coma diminishes, the hearing is restored,
then the sight; and finally, the inability
to speak,  and the difficulty of using the
tongue, disappear.
  In the form of apoplexy  which is ac-
companied with paralysis we have ordina-
rily, in the first instance, the same condi-
tion of the brain precisely as in the sim-
 (Pathology.)                       Z£i

pie form of the disease.  In the greater
number of cases, the patient is first seized
with torpor, more or less complete, of the
sensorial powers, to which succeeds, after
a longer or shorter interval, paralysis of
one side of the body; the first  period of
the attack indicating a state of irritation
and general congestion of the brain, the
occurrence of  paralysis being invariably
connected with disorganization  of a por-
tion of the brain, produced for the most part
by an effusion  of  blood from  the vessels
seated within its substance.  If the effused
blood  be small in quantity, and  confined
strictly  to the  apoplectic  cavity  that has
been formed in the midst  of the  cerebral
mass, and at the same time the conges-
tion of the brain is abated or removed, the
patient  recovers from  the state of  coma,
but the paralysis  persists.  If the  disor-
ganization  of the  brain has  occurred  on
one side only,  the loss of motion and of
sensation  is confined  to one  side of the
body,  and, in almost every instance, on the
side opposite to that on which the  extra-
vasation takes place.  If both hemispheres
of the brain are the seats of extravasation,
there results a paralysis  of both sides of
the body.   When the amount  of blood ex-
travasated  is considerable, the symptoms
of coma disappear very slowly;  hence, as
remarked by Cruveilhier, the persistence
of stupor is always a  bad symptom, indi-
cating  either a very  extensive effusion
within  the substance of the brain,  or the
communication of the apoplectic cavity
with the ventricles or surface of the organ,
or with both.   The effusion of blood, and
consequent injury to the brain, may be so
great as to cause almost immediate death.
  In  all the  apoplectic  cases  in which
death took place at the end of a few hours,
Cruveilhier  found that  the blood had
burst  into  the  ventricles  or between the
convolutions.   Sometimes  the   paralysis
which ensues is universal; the mouth is not
drawn to either side, and the  patient dies
as from asphyxia, or as animals  in  whom
both the pneumo-gastric nerves have been
divided.  Dissection, in such cases,  show3
that the extravasation has taken place in
the substance  of  the  tuber annulare, or
has burst from thence along  the base of
the skull.   All the facts which have been
collected, show, that it is  to the  disorgan-
ization of the brain, the persistent  para-
lysis  is  invariably owing;  and  hence  it
may occur  equally whether the brain be
disorganized from effusion of blood, from
acute  or chronic  inflammation,  or from
any other cause.
  The  paralytic  symptoms,  in  cases of 
226
APOPLEXY.  (Treatment.)
apoplexy, may disappear gradually as the
blood is  absorbed, and the ruptured sur-
faces of the brain become reunited by a
kind of cicatrization.  The possibility of
the perfect and entire disappearance of the
palsy, has been proved by Riobe, Briche-
teau,  and others; but in general it  is
permanent, or, at ieast, the patient expe-
riences, during the remainder of his life,
a debility, more or less considerable, of the
functions of sensation, of voluntary motion,
and of the  intellect.
   In many instances,  after a prompt re-
covery from a first attack of apoplexy, the
disease  recurs sooner  or later.  If the
case has been merely  one of the  coma-
tose form of the  disease,  and  the  patient
neglects subsequently  those  precautions
which his situation so imperiously demands,
in a very few hours he may be seized with
a fit of a more serious or fatal character.
The act of vomiting, violent sneezing,
a  sudden change of position, or a slight
shock  or  excitement  of the  mind,  is
often the  exciting cause  of  the  second
attack.  More commonly, however, the
latter does not occur until after an interval
of  a  week,  or  longer.   When  it takes
place  about  the  eighth or ninth day,  it
may be  attributed,  pretty generally, to
either a renewal of the  congestion  and
effusion of blood, occasioned  by the parts
surrounding the original apoplectic cavity
becoming  inflamed, or  to an extensive
softening of the cerebral mass.
   Apoplexy, with lesion of the substance
of the brain, most commonly attacks sud-
denly, particularly in corpulent persons,
of  plethoric  habits and short necks, and
who lead  luxurious, intemperate or de-
bauched lives. A few moments before the
invasion of the disease, the brain exhibits,
occasionally, an extraordinary excitement
accompanied  by an unusual vigour of in-
tellect, and an energy of expression which
the individual had never before exhibited.
Sometimes, a numbness of one side of the
body, or of the face, or a fixed pain in the
head, precedes the attack; more frequent-
ly, an embarrassed state of the tongue, or
a  difficulty of pronouncing certain words
or letters.  These symptoms may, however,
disappear,  especially if a  spontaneous he-
morrhage  occur  from the nose, or from
hemorrhoides,  or if bleeding or  active
purging be resorted to, without the apo-
plectic seizure resulting.  Whether pre-
ceded  or not by  premonitory symptoms,
the face, at the instant of attack, assumes
an unusual hue,  the cervical and facial
veins swell,  the  tongue falters, the sight
is obscured, the hearing blunted, and the
individual is finally deprived of sensation
and of consciousness, and falls down  in a
state of coma, upon that side which is  sub-
sequently to become paralytic.  In a few
hours after the attack,  provided  the brain
has not already suffered  laceration  from
effusion of blood, the respiration becomes
considerably slower than  natural.  The
venous blood, in consequence, experiences
a mechanical obstruction  in  its  return to
the heart; and the latter organ begins, in
proportion, to react: the pulse,accordingly,
becomes hard and frequent; the artery, as
it were, vibrates under the finger.  The
force and hardness of the pulse continue
until extravasation takes place in the  sub-
stance of the brain, when it becomes small,
quick, and concentrated.   During the  first
period of the attack, respiration is equal on
both sides of the body:  it continues so,
sometimes, even for days.   But ultimately
the thorax becomes unequally dilated; one
side of the chest is,  as  it were, struck
motionless, while the  other seems to re-
double its activity;  the chest also appears
flatter on the  inactive side than on the
other.   This symptom so generally  pre-
cedes  the paralysis, that the latter may
usually be  predicted  when  the  first ap-
pears ; and  Serres believes it may even
be prevented, by proper remedies resorted
to at this period.  The sensibility is some-
times  equally obtuse, on both sides of the
body, before paralysis has taken place; but
often more strikingly so, on the side which
is to become paralytic.  Hemiplegia finally
occurs.  Serres, who has passed whole
days and nights at the bed-side of apoplec-
tic  patients, watching the  various phe-
nomena presented during the progress of
the attack, has seen distortion of the mouth,
preceded several hours by certain convul-
sive movements of the side  subsequently
deprived  of nervous  power.  Sometimes
the hemiplegia was preceded by an almost
tetanic rigidity of the  whole side.   Occa-
sionally, paralysis  appeared  first in the
muscles of  the mouth; at other times, in
those of the extremities; the lower limbs
being always paralyzed before the superior.
Sensibility will sometimes continue in the
affected  limb; but, more commonly, loss
of sensation precedes and accompanies the
loss of motion. (Annuaire Mid. Chirur. I.)
   Treatment.  In few diseases have the
curative means, proposed by different wri-
ters, been influenced, to a greater extent
by hypothetical views entertained in  rela-
tion to their pathology, than in apoplexy.
In consequence of this, the most dissimilar
and even opposite  modes of treatment
have been, by  turns, recommended and 
APOPLEXY.  (Treatment.)
227
denounced.  According to one authority,
the cure of the disease  is  to be  trusted
solely to profuse and repeated bleedings;
while,  according to another, a  moderate
bleeding is proper only at the very onset
of the  attack, and when it  is one.of san-
guineous apoplexy;  but  subsequently, or
in the serous form of the disease, the loss
of blood, in any quantity, is not only use-
less, but decidedly injurious.  A third class
of practitioners trust solely to the use of
purgatives or emetics; a fourth object to
both, but urge the necessity of resorting at
once to stimulants and tonics;  while an-
other,  of equal  eminence,  adopting  the
maxim  of Hippocrates, that it  is impossi-
ble to cure a strong apoplexy, and very dif-
ficult to cure a feeble one, discard  the use
of all active remedies, and leave the patient
entirely " to the efforts of nature." Not-
withstanding experience  as well as theory
is invoked in favour of all these plans of
treatment, yet when we come to test them
carefully by their general results, the real
value to be attached to each will be very
readdy determined; and we shall find,
that the weight of testimony derived from
this source, is greatly in favour of those
remedies which the  phenomena ordinarily
attendant upon the disease,  as well as the
best established views,  in  regard to its
pathology, would have pointed out a priori.
   It is  unquestionably true, that in m ny
cases of apoplexy,  the injury  which the
brain has suffered is such, that death must
inevitably ensue, whatever may be the
treatment pursued, or however promptly or
energetically it may be carried  into effect;
whilst,  in other instances, a perfect recove-
ry will  take place when the remedies have
been, apparently, the most inefficient.   In
a few cases, the apoplectic symptoms have
been even known to disappear spontaneous-
ly; and that in a very short period.  Never-
theless, the  disease is  one in which  a
judicious plan of treatment, early institu-
ted, will, in the greater number of cases,
be productive  of decided benefit; either
restoring at once the functions of the brain,
or, at least, arresting the fatal termination
of the  attack, and preserving the patient
from a state of decrepitude for the remain-
der of his days.
   The remedies which experience  has
shown to be  the most efficacious in  the
treatment of apoplexy, are bleeding, gene-
ral and topical, cold  applications to  the
scalp, counter-irritants to the extremities
and surface of the  body, purgatives, blis-
ters, and such other means as  are calcu-
lated to abate or remove  cerebral irritation
and congestion.  Previously to entering
upon the consideration of those remedies,
it will be proper to point out certain mea-
sures necessary to be carried into effect
immediately  upon the occurrence of the
disease, and before even the more active
remedies are commenced with.
  The first thing to be attended to by the
physician, when called to a patient labour-
ing under  an  attack of  apoplexy,  is to
loosen or remove all  such portions of his
clothing as may be  supposed capable of
compressing  any part of his  body,  more
especially the neck, chest, and abdomen;
the patient, at the same time, being placed
in such a position as will  have the  least
tendency to  prevent  the  free return of
blood from the vessels of the head, and
removed, with the least possible agitation,
to a large,  cool, and well-ventilated cham-
ber, and placed upon a mattress, with his
head and shoulders very considerably ele-
vated.  This latter direction, Serres, with
great propriety, insists  upon, as a matter
of no trifling importance, having himself
seen the most fatal results from its neglect.
He even recommends the patient, when it
is practicable, to be supported in a sitting
posture.  In addition to  these  measures,
it is strongly recommended, by many emi-
nent  practitioners, to cover the  head, pre-
viously shaved, with  cloths wet with cold
or iced water, and at  the same time to im-
merse the feet in hot water, or to  apply
frictions, with  some stimulating liniment,
over the whole of the lower extremities;
and the recommendation, we are  con-
vinced, is a very judicious one, in nearly
every case.  The remedies which are next
to be resorted to, as well as one or two that
have been proposed, but, in our  opinion,
either of doubtful propriety, or absolutely
injurious, will  now be considered.
   1.  Bleeding.  The subtraction of blood
is unquestionably one of the most  effica-
cious  means we possess  for  the  cure  of
apoplexy.  Employed at a sufficiently early
period  after  the attack, it will  frequently
very promptly remove  the congestion  of
the cerebral vessels,  often prevent exten-
sive extravasation of blood, and preserve
the  substance  of the brain from rupture
and disorganization.   Even at a later pe-
riod, it will,  in many  cases, greatly amelio-
rate the symptoms, prevent the extension
of the  injury which  the  brain  may have
already received, promote the  absorption
of the  effused fluids, and the contraction
 and cicatrization of  the apoplectic cavity.
 Bleeding,  it  is true, has been objected to,
 in  the treatment of apoplexy, by  a few
 respectable writers; and its use, by others,
 is restricted  to certain forms of the disease. 
228
APOPLEXY. (Treatment.)
The objections, however, that have been
made to the general employment of blood-
letting, in the early period of the attack,
and  its cautious repetition, at a more ad-
vanced stage, will be found, we apprehend,
to be purely hypothetical, and based upon
erroneous views of the  character of the
disease, or to hold good solely against the
abuse of the remedy.   To say nothing of
the concurrent evidence borne in favour of
the  good effects of blood-letting, by  the
great majority  of  those  medical writers
whose opinions, on practical subjects, are
the most deserving of respect,  the very
symptoms by which the disease is ordina-
rily accompanied, the  morbid state of the
brain, revealed by dissection, and the fact,
that spontaneous and copious hemorrhage
from the nose, lungs, or hemorrhoidal ves-
sels, have either prevented the occurrence
of the attack, when the most unequivocal
symptoms of its approach have been pre-
sent, or completely removed the disease
when it has occurred,—all press upon the
attention of the reflecting practitioner the
importance and necessity of blood-letting
in the treatment of apoplexy.  And we are
persuaded,  judging from our own  expe-
rience, that more  advantage is to be  ex-
pected, in the generality  of cases, from its
use, than from  almost any other remedy.
Whenever, therefore, the  attack is recent,
and  occurs  in a plethoric  habit, accom-
panied with a full, active pulse, and more
especially, when we have evident symp-
toms of an  undue  determination of blood
to the vessels of the head, no time should
be lost in resorting to the abstraction of
blood, and carrying it  to such  an extent as
may be demanded by the emergency of the
case. Even when the indications for gene-
ral blood-letting are not so strongly mark-
ed as in the cases just referred to, or after
the free use of the lancet  the topical ab-
straction of blood,  by  means especially of
cups to the  head, will almost invariably be
called  for.   Indeed, we  can  conceive of
few cases of genuine  apoplexy,  in which
the remedy employed, in  one or other of
these ways,  can' with propriety be dis-
pensed with.
  Some difference of  opinion has existed
among physicians  as  to  the  part of  the
body from  which  the blood should be
drawn; some preferring  the  opening of
the jugular veins, others recommending
the division of the temporal arteries, and
others, again, with Aret^eus  and  Mor-
gagni, insisting upon the superior effica-
cy of bleeding from the  occipital veins;
whde  many of the  continental  physi-
cians prefer bleeding  from the feet, these
 being first immersed in  hot water; this
 is especially recommended when the apo-
 plectic attack has immediately succeeded
 to  a suppression of some  habitual  eva-
 cuation, or has been caused by metasta-
 sis of rheumatism or gout.  We confess,
 however, that in practice we have seen no
 particular advantage which the detraction
 of  blood from any other part of the body
 has, over  bleeding  in the  usual manner
 from the arm.  We  are fully aware, that
 in  cases of local congestion, as a general
 rule, the  nearer we  take the blood from
 the part in which the disease is seated,
 the better; yet, as the great object of the
 bleeding, in the first period of the disease,
 is  to diminish promptly  the mass of the
 blood  in the vessels, and reduce, at once,
 the action of the heart,  a large  bleeding
 from the arm, will be equally effectual, if
 not preferable, to either dividing  the tem-
 poral arteries or opening the jugular veins;
 subsequently, however, a judicious resort
 to topical blood-letting will be all-import-
 ant  The dispute which at one period ex-
 isted among physicians as to the propriety
 of  drawing blood from the  sound or the
 paralyzed  side, must now  be considered
 altogether puerile: it is  of little moment
 which  side  is made choice of,  provided
 the bleeding be resorted to with sufficient
 promptitude and carried to a proper extent.
   In general, the loss of a considerable
 quantity of blood will be  demanded at the
 first bleeding; nevertheless, the only rule
 that can be  laid down by which to mea-
 sure  the extent  of the evacuation, is the
 effect produced by it upon the symptoms
 of  the case.   Cheyne directs two pounds
 to be drawn  off at first, and he has known
 from six to eight pounds taken from a per-
 son by no means robust, before the disease,
.which ended favourably, began  to yield.
 The  bleeding should undoubtedly be car-
 ried to such an extent  as  to produce a
 marked  reduction in the action of the
 heart; and to effect this as quickly as pos-
 sible, the  blood should be drawn from a
 large orifice.  Gregory even advises that
 two veins be opened at  the same time;
 and we believe  that general experience
 will confirm the  remark of Cruveilhier,
 that one large bleeding, at the very com-
 mencement of the disease, will produce a
 much more  beneficial effect than the re-
 peated abstraction of small  quantities of
 blood at short intervals.
   In thus  recommending the prompt and
 free abstraction of blood, in the early period
 of the apoplectic attack, we would not wish,
 however, to be understood as directing it
 to the same extent, indiscriminately, in all 
APOPLEXY. (Treatment.)
229
cases.   We agree entirely with  the  ob-
servation of Abercrombie, that in the  ex-
tent of our evacuations, a due regard is
always to be had to the age  and constitu-
tion of the patient, and to the state of the
pulse.   But, with that gentleman, we  are
also convinced, that there^are no symp-
toms which characterize a distinct class
of apoplectic affections requiring any  im-
portant modification in the treatment;  or,
in other words, a class which, in their  na-
ture, do not admit of blood-letting; while
in most  cases of the disease,  we repeat,
the free use of the  lancet is  almost  the
only means  by which the life of the  pa-
tient  can be saved,  or his permanent  de-
crepitude prevented.
   Subsequently to general blood-letting,
and more especially if the symptoms of
the case have not been very decidedly
ameliorated, the local abstraction of blood
should invariably be resorted  to; by  the
application of cups or of leeches to  the
temples, occiput, nape of the  neck, or to
the shaved scalp.  Cruveilhier  advises
leeching along the course of the jugu-
lars ; but as a general rule,  admitting of
few exceptions, we should prefer  the  ap-
plication of cups to the head or back part
of the neck.   The cups, when scarifica-
tions  are freely made, draw off the blood
much more promptly than  leeches, and
tiie irritation which they produce,  has
often  appeared to us to  act beneficially,
by  unloading the vessels  of the brain.
Gregory has seen the application of cups
rouse the patient, when bleeding from  the
arm had been productive of apparently no
effect   Dreysig notices  the same fact
{Handwbrterbuch der Med. Klin. I. 450.),
and it is confirmed by our own experi-
ence.
  In cases of apoplexy,  Cruveilhier is
in the habit of drawing blood from  the
mucous  membrane  lining  the  nostrils,,
either by scarifications, or by the applica-
tion of leeches within the  nose;  and he
bears very decided testimony in favour of
its advantageous effects.  (Med. Clinique.
1821.) In consequence, also, of the bene-
ficial  change frequently produced in  the
symptoms of the disease by spontaneous
discharges of blood from the hemorrhoidal
vessels, that gentleman suggests the pro-
priety of applying leeches to the  margin
of the anus.  The detraction of blood from
this part, will, no doubt, often be attended
with the very best effects.
  In regard to the  extent and repetition
of topical depletion, much must be left to
the judgment of the practitioner, it being
impossible to lay down any  general rule
  Vol. II.                             20
in relation to it The effects produced by
the previous bleeding,  and the character
of the symptoms which remain, must be
taken  into account in deciding upon the
suspension or continuance of the remedy.
   2. Cold Applications. We have already
advised the  head of the  patient to be
shaved, and the scalp to be  then covered
with  cloths wet with  iced  water.   The
application of the latter should invariably
be resumed after the cupping,  and perse-
vered in so long as symptoms  of cerebral
irritation and congestion, with heat of the
head and  flushed and tumid countenance
continue.   In violent attacks,  the appli-
cation  to  the head, of even powdered ice
inclosed in a bladder,  will be advisable.
Abercrombie recommends, whilst the pa-
tient  is supported in a sitting posture,  a
stream of cold water to be poured upon
the crown of the head and received in  a
basin held under the chin.   He gives an
example of a girl quickly restored by this
means, from  a state of what he believed
to be decided apoplexy. Of the beneficial
effects resulting from the sedative impres-
sion of cold  applied to the scalp in all
cases of apoplexy, there cannot be a doubt.
For the simple forms of the disease,  it
may almost be ranked, in consequence of
the promptness of its action, upon a level
with direct depletion. (Cruveilhier, Thi-
lenius.)  In  general, as soon  as the tem-
perature of the head becomes natural, and
the fullness of the  features entirely sub-
sides, especially if at the same time they
become pale, the cold applications may be
omitted; but on the return of heat or of
a  flushed appearance  of  the  face, they
should  be immediately resumed.   Even
after the  comatose  symptoms  have disap-
peared, frequently sponging the head with
cold water, the hair being at the  same
time kept short, will be found of decided
advantage.
   3. Counter-irritants.   Simultaneously
with the  application of cold to the scalp,
counter-irritants to the lower extremities,
in the form of sinapisms, or stimulating lini-
ments, may be resorted to with  good effect.
In relation to the use  of these remedies
in apoplexy, some little difference of opi-
nion, however, exists among practitioners;
some objecting to them entirely as inju-
rious,  while  others consider them as of
little or no benefit. But the weight of ex-
perience is in favour of their early employ-
ment in all cases of the disease.  With
Cruveilhier, we are persuaded that it is
during the presence of the comatose symp-
toms, that their  good effects will be the
most decided. 
230                       APOPLEXY.  (Treatment.)
  4. Purgatives.  After blood-letting, the
most powerful remedy in cases of apo-
plexy is, unquestionably, active'purgation.
In regard to its beneficial effects and its
general propriety in all cases of the dis-
ease, less difference of opinion exists than
in relation  to  almost any other remedy
that has been proposed.  Abercrombie re-
lates several cases in which little effect
seemed to result from blood-letting, where-
as an evident improvement took place im-
mediately after copious alvine evacuations
were procured.  Johnson states that his
experience is in unison with this observa-
tion (Med.  Chirur. Rev.  I. 24.),  and we
can say the same.  To obtain a free  and
copious discharge from the bowels should,
therefore, be attempted at as  early a pe-
riod as possible of the attack.   In severe
cases it is always difficult however, often
impossible, to cause the patients to swal-
low  any medicine given  by the mouth;
hence, as a general rule, immediately after
the first bleeding, an active purgative ene-
ma should  be administered, and repeated
at short  intervals, until a full evacuation
from the bowels is procured.  The article
most readily obtained  is, perhaps,  soft
soap, of which two or three table-spoonfuls
may be dissolved  in  a pint or more of
warm water, for an injection;  and, if re-
quisite, its  activity may be  increased by
the addition of common salt or a strong
infusion of senna leaves  in combination
with the sulphate of magnesia or soda;  a
solution of aloes in warm water; or any
other of the usual purgative enemata, may
be employed. In many cases, an injection
of a drachm of spirits of  turpentine sus-
pended in mucilage of gum acacia or thin
starch will  be found very  prompt and ac-
tive  in  its  operation.  Cruveilhier  re-
commends  adding to  the  injection made
use of, a 6mall quantity of tartarized an-
timony, so  as  to obtain  its  depressing
effects upon the  circulation without  ex-
citing vomiting.  Richter even advises
injections of a  solution of tartar emetic;
we should strongly doubt  their propriety,
however. Irritating enemata are enjoined
by Aret*:us and Forestus, and by many,
also, of the modern writers, particularly
Thilenius. Free catharsis may sometimes
be produced by placing a drop or two of
Croton oU upon the patient's tongue;  we
have repeatedly seen it produce no effect
however, when used in much larger doses,
and  when purgative enemata have ope-
rated effectually.
  The moment the patient can be made
to swallow, a large dose  of calomel and
jalap or  other active cathartic, followed,
after a short  interval, by an infusion of
senna, or by  purgative injections, should
invariably be prescribed.  But it is not
merely necessary  to  purge  during the
early period  of the attack;  the  bowels
should be also kept in a lax condition so
long as the disease continues, by the judi-
cious administration of purgatives at pro-
per  intervals.  The one from which we
have derived the most advantage is the
compound powder of jalap.
   When the attack has succeeded to the
sudden cessation of a hemorrhoidal  dis-
charge, some advantage is supposed to
result from a combination of aloes, soap,
and  the blue  mass, or of aloes and colo-
cynth or scammony.
   After  the  attack  is so  far  mitigated
that the patient has recovered the power
of deglutition, Copland states that he has
often seen decided advantage derived from
a mixture of half a drachm of spirits of
turpentine and the same quantity of castor
oil;  particularly when the bowels  are re-
quired to be freely acted upon.  If neces-
sary, the  same dose may  be repeated a
second or  third time, at intervals of from
twelve  to  twenty-four hours.  This pre-
scription, he remarks, will promote a more
complete  revulsion  from the head  than
any  other  means that can be employed,
particularly when preceded by calomel or
other cathartics,  and  followed  by active
enemata.  (Diet. Pract. Med.)
  5.  Blisters.  By Cullen and some later
writers, the early application of a blister
to the scalp or nape of the neck is strongly
recommended in the treatment  of apo-
plexy, while by others, the practice is as
strongly reprobated.  The decision on this
question must be drawn from  the general
result of experience, and this appears to
be in favour of the  remedy;  a very great
discrepancy of sentiment  exists,  never-
theless, as to the  stage  of  the  disease
when their effects  are most beneficial.
Cruveilhier  considers them proper only
during the comatose stage, and others re-
strict them to a  later period of the at-
tack.  Most of the more recent writers,
also, with  Portal condemn  their appli-
cation to the  scalp, and we  think with
great propriety.   Judging from  the facta
that  have fallen under our own notice, we
should say, that blisters ought not to be re-
sorted to, until after depletion by the lan-
cet and by cups  has been pretty actively
employed: subsequently, however, much
advantage  will certainly  be  derived,  in
many cases, from blisters applied to the
nape of the neck, between the shoulders,
or on the inside of the thighs or legs. 
APOPLEXY.  (Treatment.)
231
  6. The Actual Cautery or Moxas.  Se-
tons and Issues. These have all been ad-
vised, from a very early period of our sci-
ence, in the treatment of apoplexy.   The
first may be useful, occasionally, in des-
perate cases;  especially when the stupor
continues, after a fair  trial has been made
of the remedies already detailed.   The
two latter can scarcely be considered pro-
per, excepting as prophylactic measures,
or  in the  consecutive  treatment of the
disease.
  7. Frictions of the Skin.   These are
strongly recommended  by Cruveilhier,
as well during the comatose stage as sub-
sequently.  He directs  them to be  made
with a flesh-brush, or the hand, over the
whole surface  of the body.  Abercrom-
bie, also,  speaks of their good effects  in
the most positive terms. The remedy cer-
tainly deserves attention.  We are con-
vinced it will be found particularly useful
after the patient is  roused from the  state
of  deep stupor with  which  the attack
generally  commences.
  8. Emetics.  To determine how far the
employment of emetics is useful in apo-
plexy, or even whether they are at all ad-
missible, would be very difficult were we
to content ourselves with merely collating
the  discordant opinions  of different wri-
ters on the subject.   While by one  class
the  good  effects of emetics  are insisted
upon in the most positive terms, during
particular  stages, or, at least in certain
forms of apoplexy, by another they are as
positively denounced as invariably a doubt-
ful,  and often  a decidedly injurious pre-
scription in every stage and variety of the
disease.   On  both sides of the question,
we find arrayed, in nearly equal propor-
tions,  many of our  most  distinguished
medical authorities. Notwithstanding this
decided opposition of opinion, founded in
a great measure upon hypothesis, and de-
riving little or no support from facts, we
conceive that the  question may be  very
readily settled by an attentive  considera-
tion of the phenomena generally attendant
upon the apoplectic attack, compared with
the best established views in relation to
its pathology, and the well-known imme-
diate effects produced by the operation of
the remedy.  In the general run of cases,
there is certainly nothing in the symptoms
of apoplexy indicating the necessity of a
resort to emetics, while from the condition
of the brain during  the attack, and the
flushed  and tumid  face, bloodshot  eyes,
and  other symptoms of  an interrupted
circulation in the vessels of the head, or-
dinarily observed during the act of vomit-
ing, the impropriety of their employment
would appear to be clearly pointed out. It
may be added, also,  that  in the predis-
posed,  the apoplectic seizure  has been
brought on, not unfrequently, by the vio-
lent straining  often  attendant upon  the
operation of an emetic. We have no hesi-
tation, therefore, with Cullen, Walther,
Cheyne, Cruveilhier, the elder Richter,
Portal, Rochoux, Serres, and the greater
part of the recent writers on the disease,
in proscribing  emetics entirely from  the
treatment of genuine apoplexy.  It is re-
marked by Portal, that in violent cases,
previously  to the compression being re-
moved  from  the origin of  the nerves,
emetics, even  in the largest doses, will
frequently  have little or no effect upon
the stomach.
  A state  of coma does, however, occa-
sionally occur, strongly simulating that of
apoplexy, in which the operation of an
emetic is  certainly decidedly  beneficial.
The attack, in the instances to which we
refer,  always  takes  place a 6hort time
after eating voraciously  or immoderately
of rich and indigestible food, and seems to
be  induced solely by the over-distension
and irritation to which the stomach is thus
subjected.  For, when the contents of the
latter are evacuated, either by spontaneous
vomiting or by the exhibition of an emetic,
the coma  almost instantly disappears, and
leaves, in  general, the patient free from
any symptoms of  cerebral  disease.   If,
however, relief be  not in this manner ob-
tained at an early period of the attack, all
the  phenomena of genuine apoplexy are
developed, as  we  have  had occasion to
witness in more than one instance.
   In these cases  of spurious apoplexy, -as
they have been termed  by some writers,
the patient, immediately after eating, is
suddenly deprived  of sense  and motion,
and lies as one in a state of syncope;  the
face is pale;  the  eyes  are  fixed  and
staring; the  pulse  small, weak, and  fre-
quent ; the breathing without stertor, slow
and  scarcely perceptible; the  surface of
the body is often cool and clammy. When
the epigastrium is  examined, it is  found
tense and greatly distended. Although in
such cases, we would always advise  the
prompt administration of an emetic,  we
should not, however, neglect, at the same
time, the application of cups  and of cold
to the head, and the immersion of the feet
in hot  water,  followed by sinapisms to
these parts.
  9. Stimulants.   It  has been usual, re-
marks Cullen,  for practitioners, together
with the remedies already enumerated, to 
232
APOPLEXY.  (Treatment.)
employ various kinds of stimulants; but I
am disposed to think them generally hurt-
ful;  and they must be so whenever the
fullness of the vessels and the impetus of
the circulation are to be diminished. Upon
this  principle  it is therefore agreed that
stimulants are absolutely improper in what
is supposed to be sanguine apoplexy; but
they are  commonly believed to be proper
in the serous.  If, however, we be right
in alleging that  this also  commonly de-
pends upon a plethoric state of the blood-
vessels of the brain,  stimulants must be
equally improper in the one case as in the
other.  (First Lines,  (> 1135.)  Notwith-
standing the use  of stimulants is advo-
cated by  medical  writers  of a very late
date, in certain stages and  forms of apo-
plexy,  yet, the judgment pronounced  by
Cullen in relation to their employment,
is so perfectly in accordance with our own
views, generally speaking,  of the nature
and treatment of the disease, that we need
add nothing to it:  under all circumstances,
and at  all periods of apoplexy, we consider
their administration to be  in the highest
degree hazardous; often they cannot fail
to prove  eminently injurious.   The prin-
cipal of the recent writers who advise the
use of stimulants are Richter (Med. Chi-
rurg. Bemerk.  II. 110.), Cooke (Nervous
Diseases.  I. 337.),  Abercrombie  (Re-
searches on the pathology of the brain in
apoplexy), and Copland.   (Diet. Pract.
Med.)
  From what has been said, it must  be
evident, that during a fit of apoplexy, our
chief dependence for its removal,  must be
upon prompt and active depletion by blood-
letting, general and topical, and  purga-
tives, regulated in extent  and  repetition
by the  violence of the symptoms and the
age  and  constitution of the patient;  in
conjunction with  a proper position of the
body, cold to the  head, and counter-irri-
tants to the extremities. It  will be proper,
in all cases also, to inquire  into the state
of the  urinary  discharge, lest injury re-
sult  from accumulation  of urine  in the
bladder, which  should be prevented by an
immediate resort to the catheter.
  When consciousness has returned, and
the patient is  recovered  from the imme-
diate effects of'the attack, the state of the
pulse, the remaining symptoms, the gene-
ral condition of the different functions  of
the system, and the extent to which, also,
depletion  has  been already carried, will
indicate the subsequent treatment which
is to be adopted. The patient should inva-
riably be preserved in a state of the most
perfect quietude both of mind and  body;
all unnecessary exertion, or excitation of
either, is therefore to be carefully avoided.
If any food be allowed, it should be very
sparing in quantity, and of the least  irri-
tating quality; it would be better, in fact,
to confine  the patient for some time to
toast-water, water gruel, or  thin panado,
and  even these should be  sparingly  in-
dulged in.   Flesh, and vinous, malt, or
spiritous liquors, must be strictly and ab-
solutely prohibited.  A laxative condition
of the bowels should be preserved by the
occasional administration of active puron-
tives and injections. The remaining symp-
toms will frequently indicate the neces-
sity  of a repetition of blood-letting, espe-
cially topical bleeding by means of cups
or leeches to the head.   In many cases,
also, some advantage will be derived from
antimonials, especially in combination with
the blue mass.  Keeping the hair short,
and  frequently sponging  the scalp with
cold water; as well as brisk and repeated
friction of the whole surface of the body,
are important measures, that ought never
to be neglected.   The patient, likewise,
should sleep, at night, on a hair mattress,
with his head and shoulders considerably
elevated.
  The symptoms which succeed to the
attack of apoplexy have a  close relation
to the changes which take  place at the
seat of lesion in  the brain.   The  absorp-
tion  of the  effused blood, and the process
of cicatrization in  the apoplectic  cavity,
require, ordinarily, several months for their
completion; during the whole  of which
period the patient is in imminent danger
of a recurrence of the disease from very
slight causes.   The utmost care therefore
should be observed to prevent inflamma-
tion  from taking place around  the extra-
vasated blood, and  thus occasioning a re-
turn of the congestion and  hemorrhage.
According  to  Cruveilhier, about  the
eighth day  after  the attack is generally
the most critical period, as it is then that
inflammation of the parietes,  or in the im-
mediate vicinity of the apoplectic cavity,
is most liable to occur; with either a re-
newal of the hemorrhage, effusion of se-
rum between  the membranes or into the
ventricles,  or  extensive softening of the
brain.   Hence  the great importance of
preserving the patient in the utmost qui-
etude  of body, stillness and silence, until
subsequent  to  that period;  disengaging
his senses, passions, and mental faculties,
from all undue  excitement; keeping  him
upon a low abstemious diet and promptly
reducing,  by appropriate measures,  any
tendency that may be  detected, however 
APOPLEXY. (Prevention.)
233
slight, to a renewal of the cerebral irrita-
tion  and congestion.   Caustic issues, or
setons, to the nape of the neck, or in the
neighbourhood of the  cervical vertebre,
or the use of tartar emetic ointment so
as to keep up, for  a  considerable time, a
pustular eruption on the part to which it
is applied, will often be found beneficial
measures.  Any symptoms  of gastroen-
teric disease that may present themselves,
ought to be carefully attended to, and re-
moved as speedily as possible by an appro-
priate course of treatment.   Indeed,  a
healthy condition of all the functions  of
the body will materially aid in the re-
moval of any morbid condition of the brain
that may exist  and  promote the perfect
cure of the apoplectic patient.
   Even though the patient should recover
promptly the  full power of his mental
faculties, and the strength and  free exer-
cise of his muscles, he must recollect that
his safety from a renewal of the apoplec-
tic attack will depend in a great measure
upon the caution which he observes, at all
times, subsequently, to guard against the
predisposing  and exciting causes of the
disease.  He must observe  the  strictest
temperance both in eating and drinking,
the entire abandonment of all stimulating
food and drinks;  he must  make use of
moderate but regular exercise in the open
air; sedulously avoiding the least approach
to bodily or mental fatigue,  and all undue
excitement of the feelings or passions; he
must be careful of exposing  himself to
the extremes of heat or cold, or to wet
and damp.   The preservation of the bow-
els in a free state  by regular habits, a
laxative, chiefly vegetable diet, mild pur-
gatives or injections,  is  all-important; as
well  as  early  rising, the  avoidance  of
nightly assemblies, and of crowded and
heated apartments, whether in the day or
at night
   When paralysis persists  after the  re-
moval of all the other symptoms of the
apoplectic attack,  a  particular course of
treatment will be demanded.  The pre-
sent is  not the  proper place, however, to
enter upon  its  consideration;  it will be
fully pointed out in  the article Palsy, to
which the reader is referred.
   Prevention.   It has been  correctly ob-
served by an ancient writer, that it is al-
ways of more importance to prevent than
to cure a disease.  The importance of pre-
ventive measures is very greatly increased
in relation to those affections which, like
apoplexy, are so  frequently fatal,  under
the best devised treatment, and  which,
even  when  not destructive  to life, may
leave the patient a comparatively helpless
invalid for the remainder of his existence.
To prevent the occurrence  of apoplexy
may not it is true, be possible in all cases;
but in a very large majority, we are con-
vinced, that an attack of the disease may
be entirely warded off by a prudent atten-
tion to diet and regimen; or even after a
predisposition to it has been acquired, this
may be destroyed by the same means, in
addition to the use of such  remedies as
are calculated to reduce the plethoric state
of the system,  and counteract the ten-
dency in the brain to irritation and en-
gorgement
  The prevention of apoplexy, therefore,
will depend upon a careful avoidance, as
far as practicable, of all its  predisposing
and exciting causes.  One of the most cer-
tain securities  against the occurrence of
the disease is  a constantly temperate, re-
gular, and active mode of life—equally
removed from luxurious indolence  on the
one hand, and  from the  cares and  priva-
tions of abject poverty on the other.  I
cannot, remarks Lancisi,  too frequently
repeat, that we search in vain for  a pre-
servative against the attacks of disease in
the operation of medicines, when we neg-
lect the rules of a rational hygiene. The
remedies  of the physician are deceitful;
there is but one preventive alike  effica-
cious at all times and under every variety
of circumstance, and this is to be found in
a wisely ordered course of life, and  in the
possession  of that happy  calm of mind
which is nei*her troubled by the sunshine
of success nor by the storms  of adversity.
   By those persons whose form and habit
of  body predispose them to apoplexy, the
most scrupulous care must  be observed.
Their diet must at all times be 6pare and
composed chiefly of vegetables, and their
drink, water.   They must rise and retire
early, and use daily a considerable amount
of  active  exercises,  avoiding,  however,
undue fatigue  and exposure  to extreme
cold or intense heat and all close or pro-
longed application of the mind, and every
excitement of their  passions.  Frictions
of the surface  of the body, cold sponging
of  the head, and the preservation of a re-
gular state of the bowels, are likewise
important preventive measures. The cloth-
ing should be loose, and especially should
all ligatures about the neck, chest and
abdomen, be cautiously  avoided.   If the
individual  be  affected with  any chronic
discharge from the body, whether of blood,
pus or serum, he should be extremely cau-
tious not rashly to arrest it  All those po-
sitions of the body which have a tendency 
231                                 APOPLEXY.
 to impede  the free passage of the blood
 from the head are to be guarded against.
 If at  any time,  pain  or a sense  of heavi-
 ness or over-fullness of the head, flushing
 of the face, temporary dimness of vision
 or dullness of hearing, an unusual leth-
 argy or tendency to sleep, a numbness of
 one  side of the  body or face,  or of the
 hands or feet, a difficulty of utterance or
 embarrassed state of the tongue,  should
' occur, no time must be lost  in resorting to
 blood-letting, cold applications to the scalp,
 active purgatives, sinapisms to the  feet
 and an abstemious diet.  When the above
 premonitory symptoms  frequently recur
 or are readily excited, the insertion of an
 issue or seton into the  back of the neck,
 or the  use  of the tartar emetic ointment
 so as  to keep up a  permanent  irritation,
 after cups or leeches to the temples or oc-
 ciput, or leeches  to the anus, will be ad-
 visable.  All intellectual occupation, and
 every  excitement, whether  of mind  or
 body, must at the same time be most sedu-
 lously avoided.


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APOPLEXY.—APOZEM.                         235
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                        D. F. Condie.

  APOPLEXY OF THE  LUNGS, &c.
Some modern pathologists, under the per-
suasion that the best means of advancing
our science  is to group together diseases
according to their organic lesions, employ
the term apoplexy as a generic one, to sig-
nify all spontaneous effusions of blood into •
the parenchyma of the organs or tissues.
Thus they  speak of cerebral, meningeal
and  spinal  apoplexies, of apoplexy of the
lungs, heart, muscles, liver, spleen, uterus,
placenta, kidney, pancreas, testicle, skin,
mucous  and serous  membranes,  cellular
tissue, &c.   But  the term  apoplexy was
originally applied to a determinate group
of symptoms, and not to designate a par-
ticular organic lesion; and as we do not
perceive the advantage or necessity of di-
verting  it from  its original signification,
we shall use this epithet in the sense only
in which we  have  hitherto  employed  it
(see  p. 201.).  The diseases to which the
epithet apoplexy of the lungs, heart, &c,
has  been bestowed, will  be discussed  in
the  articles on the pathological states of
those organs.                     I. H.
   APOPLEXY  OF NEW-BORN  IN-
FANTS.  (See Asphyxia.)
   APOSTASIS.  (From arto, from,  and
«jt»7fi(, I 6top.)   The  ancients employed
this in several significations:—1.  as syno-
nymous with abscess; 2. to designate the
separation of bones by fracture; 3. to sig-
nify  the  solution of a disease by some se-
cretion.                          I. H.
   APOSTEMA.  (From wprttrjfit, or a$i~
gapai, I recede from.)  This word was em-
ployed by the ancients in  a  general and
vague signification.  They seem to have
used it to designate an affection in which
parts, previously in contact are separated
by a fluid collected between them. At the
present moment its signification is no bet-
ter defined than formerly; but it is for the
most part employed as synonymous with
Abscess (q. v.).                   I. H.
   APOZEM.  (From  arto^tw,  to boil.)
cwtofyua, Gr.; Apozema, Lat  A compound
officinal preparation, the basis of which is
an aqueous infusion or decoction of one or
more vegetable  substances, to which va-
rious other simple or compound medicines,
as manna,  salts,  syrups, electuaries, tinc-
tures, or extracts,  are added.  Apozems
are always compound, which distinguishes
them from  simple  decoctions; and they
are  always taken at stated periods,  and
never as ordinary drinks,  in  which they 
236
APPARAT.—AQUED
differ from  tisans.   These preparations,
which  may be  traced  to  the  extrava-
gancies of Galenical pharmacy, have with-
in the last thirty years been gradually fall-
ing into disrepute, and are now but little
employed.                       I. H.
  APPARATUS. (From parare, to pre-
pare.) Appareil, Fr.  Anatomists and phy-
siologists employ this term to signify an
assemblage  of organs concurring in the
performance of the same function, and the
actions of which have a common object.
Thus, the mouth, oesophagus, stomach, in-
testines, liver, and pancreas, constitute an
organic apparatus, each part performing its
particular office, in effecting the digestion
of food, which is the result of their con-
joined actions.
  In surgery, this epithet is bestowed upon
the instruments and dressings required in
operations.  It has also been applied to the
different methods of operating for stone.
  In pharmacy, chemistry, &c, it signifies
a collection of the instruments employed
in these sciences, for any particular object
                                I.H.
  APPENDICULA.  The diminutive of
Appendix.                       I. H.
  APPENDIX.   (From appendere,  to
hang to.)  A part added to, or connected
with another. An appendix is always situ-
ated exteriorly to the principal body, and
is of less size than this last  Thus, the
vermicular  process arising from the  cce-
cum is  termed the vermiform appendix.
The Fallopian tubes are appendices to the
uterus, &c.                      I. II.
  APPETENCE, APPETITE,  APPE-
TITION. (From appetere, to desire.)  In
their most  extensive acceptation, these
words  signify those internal  sensations
which  impel to certain  actions,  for the
gratification of the wants of the organism.
The appetites are produced by inappre-
ciable modifications, the seat of which de-
termines the particular  appetite;  thus,
when located in  the stomach, fauces, or
genital organs, we have hunger, thirst, or
venereal desires.
  The word appetite is also very gene-
rally used in a more restricted sense, to
signify the desire for food, or synonymously
with hunger.  Physiologists  have, how-
ever, attempted  to establish various dis-
tinctions between appetite  and hunger;
thus it is said that the former is only the
first degree of the latter; that appetite is
an  agreeable sensation which promises
pleasure, and hunger an imperious want
difficult to  support, and  which soon be-
comes painful if not satisfied; that the
former  is more delicate and  capricious
than the latter,  and to be awakened re-
quires a freedom of choice in food, whilst
the latter is less exacting as to the quality
than the quantity of food. It has also been
proposed to restrict the term appetite to
the artificial  desire, or that which recurs
at the period  at which the stomach is ac-
customed  to  receive food, and hunger to
the  natural  desire.   These  distinctions
have not been sanctioned by general adop-
tioni and  it is only in the general and re-
stricted significations we have given, that
the word can with propriety be employed.
But though this double acceptation is too
firmly established by common usage to be
altered, still  science demands a greater
precision in the use of terms, and we shall
accordingly, in the present article, employ
the one in question, only in  its most  ex-
tensive signification; and refer the several
appetites to their appropriate heads. (See
Hunger, Thirst, &c.)
   The appetites being the expression of
the wants of the organism, recur with the
renewal of  these  wants,  at longer or
shorter intervals, often periodically, vary-
ing with temperature, sex, season, climate,
habit &c.  At their commencement they
are rather pleasurable than otherwise; but
if not satisfied,  they are converted into
imperious wants, become painful, and oc-
casion various derangements of the organ-
ism. (See Abstinence, and Continence.)
   The appetites are subject' to variable
pathological states: they may become ex-
alted, constituting Bulimia,  Satyriasis,
and Nymphomania, or, diminished, Ano-
rexia, and Aphrodisia;  and  finally,  de-
praved,  as in Pica and Malacia.  (See
these several heads.)             I. H.
   APYRETIC.   (From o priv. and rtve,
fire.)   oMvpvtos,  Gr.;   Apyreticus,  Lat
Without fever.                  I. H.
   APYREXIA.  (Same etymology.)  Ab-
sence of fever.  It is most commonly em-
ployed to designate the interval between
the  paroxysms  of  intermittent fevers;
though some  authors apply it also to  the
cessation of fever on the decline of acute
diseases. (See Intermittent Fever.)  I. H.
   AQUEDUCT.  Properly a  canal for
the  transmission of water.  Anatomists
have applied  it to certain canals.
   Aqueduct of Fallopius.   Canal spi-
roide de Fos temporal.  A canal  in  the
petrous portion of the  temporal bone, ex-
tending from the  internal meatus to the
styloid foramen, and giving passage to the
facial nerve.
   Aqueduct op the Vestibule.  Aque-
duct of Cotunnius. A canal commencing
in the vestibule near the common' orifice 
AQUEOUS.—ARALIA.                        237
of the two semicircular canals, and open-
ing at the posterior face of the  petrous
portion of the temporal bone.
   Aqueduct  of Sylvius.  Iter ad quar-
tum ventriculum, Canalis medius, Canal
intermediare  des ventricules of  Chaus-
sieb.  Canal forming a  communication
between  the  third  and fourth ventricles
of the brain.                     I. H.
   AQUEOUS. (From aqua, water.) Wa-
tery.
   Aqueous Humour  of the Eye.  The
limpid humour which  fills the two cham-
bers of the eye.  (See Eye.)      I. H.
   ARACHNOID.    Arachnoid  Mem-
brane.   (From  a£a%vn,  a cobweb,  and
ttoo?, like.) a^azvosvSe;, Gr.; Arachnoideus,
Tunica aranea, Lat.  This  epithet was
given by  the ancients to several mem-
branes which from their excessive  tenuity
resemble spider-webs.   Thus the  hyaloid
membrane, and capsule of the crystalline,
were thus denominated.   It is now exclu-
sively applied to the membrane of the
brain and spinal cord situated between the
dura mater and  pia mater.  (See  Brain,
Spinal Cord,  and Serous Membranes.)
                                I. H.
   ARACHNOIDITIS.  Inflammation of
the Arachnoid. (See Meningitis.)  I. H.
   ARALIA.   (Mat. Med. and Botany.)
   Sex. Syst.     Pentandria,   pentagynia.
Nat. Ord.  Araliaceae.
   Gen. Ch.  Calyx five-toothed or entire;
Corolla five-petailed;  Stamens five, often
more; Styles five, spreading; Berry5-10
seeded, crowned with  the styles;  Umbels
often with small involucres.   Beck.
   This genus forms the  type of the na-
tural  order Araliace^;,  which includes
Panax, differing from this only in having
five styles instead of two or three, and in
the fruit  being five-celled.   All the spe-
cies are  possessed of medicinal  proper-
ties; two of them have been recognized
in the U. S.  Pharmacopoeia  as officinal,
the A. nudicaulis and A. spinosa.  An-
other  of the North American species, the
A. racemosa,  also appears to be endowed
with no  inconsiderable therapeutic quali-
ties, and  has been favourably spoken of as
an application to chronic ulcers, and, ac-
cording  to Michaux, was held in great
repute among many of the Indian tribes,
as a sudorific.
   Of  the Asiatic species little is known
except the short notice of them given by
Loureiro (Flor. Cochin.), from which it
would seem that they are very analogous
in their  remedial powers, to those found
in the United States.
  1.  A. nudicaulis.  Spikenard.   False
Sarsaparilla, &c.
  Sp. Ch.  Nearly stemless; Leaf mostly
solitary, triquinate, leaflets sessile, oblong,
oval, acute, serrate, smooth; Scape shorter
than the leaf, three-cleft at the top;  Um-
bels few, small, on  long peduncles, with-
out involucres.  Beck.  This plant occurs
from Maine to Georgia, but is  most com-
mon in the northern and middle States.
It is  usually found in rocky woods in a
good soil; flowering about the end of May
and beginning of June.  The root which
is the most active part, is perennial, hori-
zontal,  of  a brown colour, cylindrical,
more  or less twisted; possessing a fra-
grant, balsamic smell, and a warm,  aro-
matic, sweetish taste.  It is  known in
many parts  of the  United States by the
name of Sarsaparilla, the root  closely re-
sembling that article, and possessing much
the same properties, being a mild stimu-
lating diaphoretic and alterative, and may
be advantageously substituted for it.  It is
much u^ed in some  parts of the country.,
in rheumatic, venereal, and cutaneous af-
fections.  Dr. Mease states that a watery
infusion  has been  found useful in zona,
and also as a tonic in dyspepsia.  The
doses  and mode of administration are the
same as those of Sarsaparilla.
  2. A. spinosa.  Angelica.  Prickly El-
der, &c.
  Sp. Ch. Arborescent; Stem and Leaves
prickly; Panicle much branched;  Umbels
racemose. Persoon. This species is found
from New-York to  Florida,  but is  most
common in the southern  and western
States.   It chiefly occurs in low, fertile
woods, flowering in  August and Septem-
ber.   It is an arborescent shrub, growing
to the height of ten or twelve feet; fur-
nished with numerous rigid prickles ; the
leaves,  which occur near the top, are
large, bipinnate or tripinnate, and prickly;
the leaflets  are oval, acute, and serrate.
The flowers are  in terminal panicles,
formed of small umbels.  The bark, root,
and berries, are all medicinal, but the first
only is recognized by the Pharmacopoeia.
This  is thin, of a  grayish colour  exter-
nally, and yellow-white within; its odour
is aromatic, and its taste bitterish, pungent
and acrid.   It is much more stimulating
than  the last mentioned species, but  is
used in the  same affections.   Dr. Mease
states that the watery infusion, when em-
ployed as a diaphoretic, should be made
very weak, as  it is  apt to create nausea
and cause great irritation of the salivary
glands in some persons.  According to 
238                         ARBOR—ARCILEUS.
Elliott, the infusion of the recent root is
emetic and cathartic.  A tincture of the
berries is said by Pursh to have been suc-
cessfully used  in  rheumatism:  from its
effects on the salivary glands, it has also
been found useful in tooth-ache.
  Bujliography.—Loureiro.  Flora Cochinen-
sis.  Ulyssypone, 1795.  4to.
  Guibourt.  Histoire abrigie des drogues  sim-
ples.  Paris, 1826.
  Merat et De Lens.   Diet  Universel Mat
Med.  I.  Paris, 1829.
  Mease, (J.) Philad. Med. Museum.  H.  161.
Philada. 1806.
  Coxe, (J. R.)   American Dispensatory.  8th
edit  Philada. 1830.
                     R. E. Griffith.
  ARBOR VITiE.  The arborescent ap-
pearance exhibited by a longitudinal sec-
tion of the cerebellum; and which results
from  the  particular arrangement of the
white substance with the cineritious.
                                I.H.
  ARBUTUS.  (Botany.)   Arctostaphy-
los, Adanson.
  Sex.  Syst.   Decandria  Monogynia.—
Nat.  Ord.   Ericeae.
  Gen. Ch.  Calyx five-parted.   Corolla
ovate, with a five-cleft orifice; pellucid at
base.   Berry five-celled.
  A.  Uva Ursi.—Bearberry.—Busseroh,
Raisin  (Fours, Fr.; Barentraube, Germ.
—Sp. Ch.  " Stems procumbent, leaves
entire."  Lindley.   This is an evergreen
shrub, with trailing stems  from one to
three feet long, the younger branches of
which rise obliquely upwards at their ex-
tremities. The leaves are scattered, thick-
ly set, upon short footstalks, obovate, acute
at  the  base,  entire, coriaceous, smooth,
shining and of a deep green colour on the
upper surface, paler and covered with a
net-work of veins  on  the under.   The
young leaves  are often  pubescent   The
flowers, which appear in May and June,
are disposed in small terminal racemes,
upon short, red, reflexed peduncles.   The
calyx is five-parted, with obtuse segments,
and  persistent.  The   corolla   is  ovate,
whitish  or reddish-white,  transparent at
the base, contracted at the mouth, and di-
vided at  the  margin into five  short, re-
flexed,  red segments.   The  fruit  is a
round, depressed, smooth, glossy, deep-red
berry, about as large as a pea, and con-
taining a white, insipid, mealy pulp, with
five cohering seeds.
   The  Uva Ursi is a native of the north-
ern parts of Asia, Europe, and America.
It  inhabits also the mountains of the south
 of  Europe, and extends, on  the  continent
 of North America,  from Hudson's Bay as
 far southward as the middle States, grow-
ing abundantly in some parts of NewJer-
sey.  It prefers a dry, barren soil, and is
found in sandy woods, on  gravelly hills,
and on elevated sandy plains.  The fruit
is sometimes  eaten, and the  leaves  are
said to be used in Russia for tanning. The
portion of the  plant medicinally employed
is the leaves.  (See  Uva Ursi.)
  Two other  species of Arbutus are no-
ticed by medical writers. The leaves  and
twigs of the  A. Alpina,  a  small  shrub
growing in the mountains of Switzerland
and the Tyrol, and  in various parts of the
north of Europe and America, have been
used as an astringent;  and the berries,
which are black,  of the  size of cherries,
and of a somewhat harsh, acidulous taste,
have been eaten as food.   The A. Unedo,
or strawberry-tree,  a native of the south
of Europe,  is  an  evergreen shrub, seven
or eight  feet  high, with a fruit which is
beautifully red when ripe,  and in size
and appearance bears considerable resem-
blance to the strawberry.   It has a sweet
ish acidulous  taste, and, though not very
agreeable,  is eaten by the  natives of the
countries where the plant grows.  By fer-
mentation  it  affords an alcoholic  liquor
from which a  spirit is obtained by distilla-
tion, sometimes used in Italy and Spain.
The leaves and bark are astringent.
                       Geo. B.  Wood.
   ARCFLEUS.  (From apty  principal,
chief, commencement.)  This term  was
coined by Basil Valentine, to designate
the universal principle, the central  fire
which, according to  this chemist consti-
tutes the source of vegetable life.  It  was
subsequently employed by  Paracelsus to
signify the primum mobile of the animal
organism, and of nature in general—the
vital  principle, which  differs  from all
chemical forces—a spiritual essence,  dis-
tinct from matter, and which in animals
has its seat in the stomach, where it is in-
cessantly occupied in converting aliment-
ary matters into blood.  According to him,
there is no other vital principle than the
archseus,  which  presides  over all  the
changes in human bodies, and alone cures
diseases, the physician merely assisting in
this process.
   These crude views were subsequently
seized upon by Van Helmont, extended
and erected  into a doctrine which,  vari-
ously modified by Glisson, Stahl, Hoff-
 man, and Cullen, has descended  to our
own days, with the title of vitalism (q. v.).
    The archaeus, as depicted by Van Hel-
 mont, is an active, intelligent immaterial
 principle, pervading all matter, the mole-
cules of which it  separates, changes, en- 
ARCTIUM.                               239
dows  with new properties, and keeps  in
continual motion; which constitutes life.
This archaeus is equivalent to the *vo£/u*>v
of Hippocrates and Galen, the sentient
soul of Plato, the nature of some authors,
the nervous power  of others,  the soul  of
Stahl,  the vital force of Barthez and
Chaussier, the vital properties of Bichat,
&c. Van Helmont  imagined the archaeus
to have  its seat at  the superior orifice  of
the stomach, whence, as from  its throne,
this king of the organism directed all the
phenomena of life.  Besides the principal
and dominant  archaeus, the writer last
mentioned conceived that there existed a
subaltern  archaeus in each viscus, whose
office it was to receive and execute the
orders of  the principal one.  To that  of
the spleen he attributed great importance,
and considered it,  with that of the sto-
mach, as constituting a ruling duumvirate.
He further imagined that the archaeus had
volition, and was  affected with anger,
fright, and other emotions.  So long as it
remained  unmoved, and the subordinate
archaei  faithfully executed its  orders, the
harmony of the system was preserved,  or,
in other words, there existed perfect health.
But when one of  the  subaltern archaei
roused  to  passion, either from caprice, or
the unusual resistance of the articles sub-
jected to  its immediate orders, the ruling
archaeus, irritated by such audacity, united
its subordinates against the rebellious one,
which too often, however, drew a part of
these last into the  revolt   The spiritual
empire  of the human body is then a prey
to all the  horrors of anarchy; each party
precipitates the actions it directs, and thus
provokes a tumult which constitutes dis-
ease.  The same thing happens when the
principal archaeus yields to a sally of pas-
sion,  from which he  is not exempt and
which induces a host  of irregularities.
   The principal object in the therapeutics
of Van  Helmont was to calm or stimu-
late the archaeus and regulate its move-
ments.  The further exposition of this doc-
trine  would  be misplaced here, and  in-
volve repetition, since it must necessarily
be discussed in the article Vitalism (q. v.).
                                I.H.
   ARCTIUM.   (Botany and Mat. Med.)
   Sex.  Syst. Syngenesia iEqualis.  Nat.
Ord.  Compositae.
   Gen.  Ch. Involucre globose, each of its
scales with  an incurved hook  at the ex-
tremity. Receptacle chaffy. Pappus sim-
ple, the rays short  Beck.
   A. lappa.  Burdock,   Bardane, Fr.;
Gemeine Klett, Germ.  Sp. Ch.  Leates
cordate, petiolate, unarmed. Linn.
  This plant is not a native of the United
States, though it is common in most parts
of the Union, growing  on road-sides, on
rubbish and in waste places; flowering in
July and August.  It is a biennial, with a
succulent pubescent stem of two or three
feet in height branching towards the sum-
mit  and  furnished  with  large,  cordate
leaves supported  on long petioles.   The
flowers are purple, and globose'.  The in-
volucre is formed of imbricate scales, each
of which terminates by a hooked  bristle
by which the seed-vessels  attach them-
selves to sheep and other animals, and are
thus  widely dispersed.   The root is  sim-
ple and fusiform, about a foot in length, of
a blackish-brown colour externally, and
white and spongy within.  By the process
of drying, it  loses about four-fifths of its
weight.  Its  smell is unpleasant though
faint;  its taste  is mucilaginous, with a
little bitterness and astringency.  No ex-
act analysis of this plant has been made.
Guibourt has detected inuline in the root
and Fee states that sugar also enters into
its composition.  The  ashes yield  about
one-third their weight of potash.
  The root is the part most generally em-
ployed in medicine, though the leaves and
seeds have likewise been recommended.
The  root is said  to be diaphoretic, depu-
rative, and diuretic.  Withering states
that  many eminent practitioners consi-
dered it equal if not superior to sarsapa-
rilla, but Cullen denies its powers as dia-
phoretic.   In Poland, however, it is said
by Bodard (Mat. Med.  II. 132.) that the
decoction has been  advantageously pre-
scribed in syphilis.  From the concurrent
testimony of those who have investigated
its real powers with care, it appears that
the decoction of the root of this plant acts
as a  mild  alterative, gently exciting the
cutaneous exhalants, though it is not enti-
tled  to the rank ofa diaphoretic. Alibert
has found it useful in cutaneous affections
attended with dryness of the skin.   The
decoction is  made by boiling two ounces
of the recent bruised root in three pints
of water down to two; of this a pint or
more is to be taken during the day.
   The leaves have been used as applica-
tions to  ulcers and  some of the leprous
eruptions,  either  simply bruised or in the
form of a strong decoction.  The seeds,
which have a bitter and somewhat acrid
taste, have been recommended as power-
fully diuretic, when  taken either  in  the
form of an emulsion or a powder, in doses
of about a drachm.  Linnveus and De-
candolle state they also possess  purga-
tive  properties. 
240                          ARDENT.—ARECA.
  Bdjliography.—I. Hill.  Management of the
good virtues of Burdock root London, 1758. 8vo.
  T Short.  Medicina  Britannica.  Philada.
1751.  12mo.
  F. Foy. Cours de Pharmacologic, &c.  I.  Pa-
ris, 1831.  8vo.
  Merat et De Lens. Diet Univ. de Mat Med.
t. 390.  Paris, 1829.  8vo.
  A. Willich.  The  Domestic Encyclopaedia.
I. 440.  Philada. 1803.
  Wood&Bache.  The American Dispensa-
tory.  104.  Philada. 1833.
                     R. E. Griffith.
  ARDENT.   (From ardere,  to burn.)
Burning, or causing great heat
  Ardent fever.  Causus, Synocha,  or In-
flammatory fever. (See Fever.)   I. H.
  ARDOR.   A sensation  of burning or
violent heat.                     I. H.
  ARECA.   (Botany.)
  Sex. Syst.  Monoecia Monadelphia.—
Nat. Ord.  Palmae.
  Gen. Ch.  Common spathe one or two-
valved.—Male.  Calyx three-parted. Co-
rolla three-petalled.  Stamens cohering at
the base.—Female.  Calyx three-leaved.
Corolla three-petalled. Nectary six-tooth-
ed.  Styles three, very short. Drupe one-
seeded.
  A. Catechu. — Sp.  Ch.   " Fronds pin-
nated ; leaflets plaited, terminal bitten off;
stem and spadices smooth." Lindley. The
Areca Catechu is a beautiful palm, from
twenty  to forty or even fifty  feet high,
with a straight, erect, round, smooth, ash-
gray trunk,  about six or eight inches in
thickness, marked, at short  intervals, with
parallel rings left by the  falling leaves,
and surmounted with  a crown  of foliage,
consisting of very  large pinnate leaves,
proceeding in all directions from the stem.
The flowers are small  and disposed in
panicles, the male being situated upon the
upper portion of the branches, the female
at their base.   They are at first inclosed
in a large, green, axillary spathe,  which
falls with the falling foliage, and  leaves
them beneath the leafy crown at the sum-
mit.   They are succeeded by fruit of a
reddish-yellow  colour becoming grayish
at perfect maturity, of the  shape and size
of a large plum, having  the  persistent
calyx and corolla at the base, and inclos-
ing, in a fibrous fleshy envelope, a  round-
ish conical nut the shell of which is brit-
tle and adheres to the exterior flesh.  On
the same plant there are  usually,  at the
same time, flowers  and fruit in all  stages
of development
   This palm is a native of Hindostan and
other parts of the East Indies, where it is
highly valued on account of its fruit This
is very astringent, and, in connexion with
\he leaf of the Piper Betel and with lime,
constitutes the masticatory so well known
under the  name of betel, and so exten-
sively used throughout the East Indies,
where it enjoys a popularity scarcely in-
ferior to that of tobacco in this part of the
world.  The red colour  imparted to the
saliva and excrements of the betel-chew-
ers is owing to the Areca nut the astrin-
gency of which  also  tends to counteract
the relaxation of bowels to which the cli-
mate so strongly predisposes.  According
to Ainslie, the fruit when young and ten-
der,  is occasionally employed, in conjunc-
tion  with other substances, in the form of
decoction, in the constipation of dyspep-
sia.  By the same author it is stated that
a strong decoction of the  nuts is used in
dyeing.
  It  was formerly thought that  Catechu
was  a product of this plant;  and there is
no doubt that in  some parts of Hindostan,
particularly in Mysore, an extract is pre-
pared from its fruit having the essential
properties  of Catechu, and used in the
East for similar purposes.  It is possible
that  some of this preparation may reach
us among the varieties of catechu brought
into  the market;  but by  far the greater
portion  of this  drug, and,  perhaps, the
only portion properly entitled to the name,
is obtained from the Acacia Catechu. (See
Catechu.)  According to Heyne, two va-
rieties of the extract of the Areca nut are
known on the Coromandel Coast one very
astringent  called  cassu, the  other  less
astringent and  somewhat sweetish, de-
nominated courry.  The former is obtain-
ed by evaporating the decoction of the
fruit as immediately  taken from the tree,
and  is of a blackish  colour  and usually
mixed with impurities; the latter  is the
product of a second decoction and  inspis-
sation, is  of a yellowish-brown colour, of
a fine earthy fracture, and free from impu-
rities, and is preferred by the betel-chew-
ers.   Ainslie gives an account of two ex-
tracts, which he says are obtained from
the Areca nut  the one of a light  brown
colour, slightly  bitter taste, and power-
fully astringent called cuttacamboo in tbe
Tamul language; the other, almost black,
hard, extremely bitter, and much less as-
tringent than the former, and called cash-
cuttie.  Both are employed  by the betel-
chewers,  but the former is greatly pre-
ferred.  He states that they are taken to
Hindostan from  Pegu and Sumatra, but
that they are also prepared of an inferior
quality  in Mysore, where they  are  used
by the native practitioners, in bowel com-
plaints, and as an external application to
sphacelous  ulcers.   They are  probably 
ARENAT.—ARGEMON.
241
identical with the  extracts above  men-
tioned by the names of cassu and courry.
  The kernel of the fruit is occasionally
brought to this country, and  kept in the
shops under the name  of Areca nut or be-
tel nut.   It is of a roundish-conical shape,
somewhat depressed,  umbilicate at the
base, rather larger than a chestnut exter-
nally of a deep brown diversified with a
fawn colour  so as to present a reticular
appearance, internally of a dark chestnut-
brown  colour with  whitish  veins,  and
whitish in the centre.   It is very hard, of
a feeble odour when broken, and of an as-
tringent somewhat acrid taste.  Besides a
large proportion of tannin, it contains, ac-
cording to M. Morin,  gallic acid, a prin-
ciple analogous to that found in legumin-
ous plants, a red  insoluble  substance, a
fixed oil, a volatile oil, lignin, and various
saline  ingredients.  (Journ.  de  Pharm.
1822. p. 455.)  In this country, it is used
almost exclusively for the preparation of
tooth-powder, for which purpose it is first
reduced by heat to the state  of charcoal.
The superiority of this form of charcoal
over that from other sources is ascribable
to the  extreme hardness of its particles.
  Another species of Areca, the A. Ole-
racea, or cabbage-tree of the West Indies,
is interesting on account of the use made
of the leaf-bud upon the  top  of its  stem.
It is the highest and most beautiful of the
American palms.  The green summit of
the trunk is formed by the sheathes of the
leaves, within which is a white heart two
or three inches in diameter, composed of
the young leaves closely folded  together.
This is taken out by  the  inhabitants and
eaten either raw or cooked, in the manner
of the  artichoke, which  it is  said to re-
semble in flavour.      Geo.  B. Wood.
  ARENATION.  (From arena, sand.)
The envelopment of  a part or the whole
of the  body in warm sand.  It is one of
the methods of applying dry heat to the
cutaneous surface, to  which it acts  as an
excitant, proportioned to the degree of
caloric it possesses; and  this excitation is
transmitted to the subjacent parts.  Sand
has the inconveniences of being heavy and
of parting too readily  with caloric; which
has led to the substitution of other arti-
cles, as bran, oats, &c. The ancients made
frequent use of this therapeutic measure,
which is  certainly useful in some  cases,
and ought not to be so entirely neglected
as it has been in modern  times. Its modus
operandi and applicandi will be fully no-
ticed elsewhere.  (See Heat, Baths, &c.)
                                I. H.
   VOL. II.         21
  AREOLA.  This is applied, 1. to the
small interstices of the capillary net-work
or between the  fibres composing the or-
gans (see Cellular Tissue, &c.):  2. to the
coloured disc which surrounds the  base
of the nipple and of all inflammatory pus-
tules  of the skin.                I. H.
  AREOLAR TISSUE. (See Angeial.)
  ARGEMONE. (Mat. Med. and Botany.)
  Sex. Syst. Polyandria monogynia.  Nai.
Ord.  Papaveraceae.
  Gen.  Ch.  Calyx three-leaved.   Petals
six. Stigma sessile, capitate, lobed. Cap-
sule superior,  with three to six angles,
semivalvular, valves three to six.  Recep-
tacle filiform, marginal, persistent Seeds
globose, striated, and punctured. Nuttall.
  A. Mexicana.  Thorn poppy. Mexican-
ische  Argemone, Germ.   Sp. Ch.  Leaves
pinnatifid  lobate, spinose; flowers axilla-
ry ; capsules five-valved.  Elliot.   This
plant is a native of Mexico,  but has be-
come naturalized in most  parts  of the
world.  It is an herbaceous annual, with
alternate, amplexicaul spiny leaves, grow-
ing to the height of about two feet.  The
flowers, which are of a bright yellow, are
succeeded by  ovate spiny  capsules, con-
taining  numerous, round, black seeds, hav-
ing a somewhat  pungent, warmish taste.
  The whole  plant abounds  with a glu-
tinous juice, which on exposure to the ac-
tion of the air becomes of a bright yellow
colour,  closely resembling that  of gam-
boge, and which, according to Long (Hist.
Jamaica.  III. 845.), has been found useful
as a hydragogue in dropsies and jaundice.
In Java, this juice  is used both internally
and externally  in cutaneous affections.
Ainslie also states that it is considered by
the Hindoos as a valuable remedy in oph-
thalmia, rubbed on the tarsus,  or  even
dropt into the eye. The seeds  are em-
ployed in the West Indies as a substitute
for ipecacuanha, in doses of two drachms
infused  in a pint of water. (Wright. Med.
Plants  West Indies.)  They  also act on
the bowels, and  are used as a purgative in
many parts  of South America. (Aublet.
Hist. Guiane.)   The  oil prepared  from
them has much  reputation in India as  an
application to tinea capitis;  it is, besides
this,  purgative.                      *
   The  flowers  are said by Decandolle
(Essai  116.) to  be used in Mexico as a
narcotic.

  Bibliography. — Ainslie.   Materia Indica.
II. 42.  London, 1826.
  Merat et De Lens.  Diet. Univ. Mat. Med
I. Paris,  1829.
                      R. E. Griffith. 
242                            ARISTOLOCHIA.
  ARISTOLOCHIA.  (Botany and Mat.
Med.)
  Gen. Ch.   Calyx none.  Corolla of one
petal, ligulate, with a  ventricose base.
Capsule six-celled, many-seeded, inferior.
Nuttall.
  This genus of  plants consists of about
fifty species,  most of which are  peculiar
to warm climates; they are, in general,
herbaceous  or shrubby,  with  erect  or
twining stems, and alternate, cordate and
entire  leaves; the  flowers are usually
axillary and  recurved.   Most  if not all
the  species  are  possessed  of medicinal
properties,  and have been regarded  as
infallible alexiterics.   It is  a remarkable
fact that a firm belief in the  efficacy of
these plants as antidotes  against the poi-
son of snakes, should exist in all parts of
the world, and among nations who could
have had no communication  with each
other;  and yet there is every reason to
believe that they possess no such powers.
  The most active part is the root; this, in
most of the species, is aromatic and stimu-
lating ; in some, however, it is extremely
acrid, and requires great caution in its ad-
ministration.   Only one of these plants is
recognized by the United States Pharma-
copoeia, as officinal.
  A. serpentaria.    Virginia  Snakeroot
Serpentaire de Virginie, Fr.; Virginische
Schlangenwurzel, Germ.  Sp. Ch. Leaves
cordate, oblong, acuminate; stem  flexu-
ous; peduncles radical; lip of the corolla
lanceolate.    Willdenow.    This  well-
known plant  is found in most parts of the
United States, growing  in  shady woods,
especially on hill-sides; it is less common
in alluvial and limestone regions.  The
root is perennial, brown, and extremely
fibrous; the  fibres are long, slender, and
of a yellowish colour when fresh.  The
stems, several of which  spring  from  the
same root, are slender, flexuous, jointed,
generally less than a foot  in height fur-
nished with  from  three  to seven leaves,
and bearing  one  to  three  flowers.  The
leaves are alternate and petiolate, oblong,
entire, acuminate, cordate at base.  The
flowers grow close to  the  ground,  on
curved, jointed peduncles, furnished with
small scales; they are of a dull brownish-
purple colour, and consist of  a  long con-
torted  tube,  enlarged at each extremity,
the border expanded into a broad irregular
margin, bilabiate,  the upper lip notched,
the lower entire.   The capsule is obovate,
six-angled, six-celled,  containing  numer-
ous rather flat small seeds.
   This plant, however, requires a tho-
rough investigation,  as  it appears highly
probable that several species are included
under the title of A. serpentaria, having
very analogous leaves and roots, but pre-
senting striking  dissimilarities in  their
flowers.  Be this as  it may, there  is  no
doubt that the Serpentaria of the shops is
furnished by more than one species; these
are the A. serpentaria, A. hirsuta (Muhl),
and A. sagittata (Muhl).  Barton (Wm.
P. C.) says that on an examination of spe-
cimens of these plants in the Muhlenberg
Herbarium  (now  in  possession  of the
American Philosophical Society), he found
that no difference was perceptible in  their
sensible properties; and Mr. D. B. Smith
states that in examining several  parcels
of the snakeroot  of the shops,  he was
able  to  distinguish three well  character-
ized  forms  of the leaves; these, he  goes
on to say, appeared to answer the descrip-
tions  of the species above alluded to;
there  was no perceptible difference in the
smell or taste of the  roots.  Hence  it
would seem that in a pharmaceutical point
of view, this confusion of species is of  no
consequence, and  affords  another proof
that  the plan adopted by the authors  of
the last edition of the United States Phar-
macopoeia,  of adopting a pharmaceutical
name for most of the vegetable remedies,
independent  of their  botanical designa-
tion, is  a wise one. (See  Serpentaria^
   Some other species of Aristolochia are
recognized by the foreign Pharmacopoeias.
These are:—
   A.  clematitis.   Aristoloche vulgaire,
Fr.;  Waldrebenhohlwurzel, Germ.
   This is a perennial plant peculiar to the
temperate and warm regions of Europe,
growing in vineyards, on  the margins  of
streams, &c.  It at  one  time  enjoyed a
high  reputation as a febrifuge and em-
menagogue, but at present is but  little
used.  The part employed is the root which
is long, cylindrical,  simple, fibrous, con-
torted, of the thickness of* the little finger,
of a  reddish or brownish-yellow  on the
exterior, and  white  or yellowish  within.
It has a weak and slightly disagreeable
odour.  Its  taste is  acrid, bitter and as-
tringent.  From the  experiments of Or-
fila it  appears that it should be given in
moderate doses, as he found that it caused
death, by a narcotic action on the nervous
system.  This root formed one  of the  in-
gredients of the celebrated Portland pow-
der, once considered as a specific in  gout
   A. pistolochia.   Aristoloche crinelie,
Fr.; Netzblatthohlwurzel, Germ.
   A perennial plant indigenous to south-
ern Europe and Switzerland.  The part
employed is the root which is composed 
ARISTOLOCHIA.
243
 of numerous  slender  fibres, about  six
 inches in length, of a yellowish-gray co-
 lour.  It has an aromatic and agreeable
 odour, and an acrid  bitter taste.   It par-
 takes of the medical properties of its con-
 geners,  and forms  an ingredient in  the
 theriac.
   A.  tonga.   Aristoloche  tongue, Fr. ;
 Langholdwurzel, Germ.
   This  species, which is found in many
 parts of Europe, is much employed in me-
 dicine by French and German practition-
 ers as an emmenagogue and anti-arthritic,
 and forms part of a great number of offici-
 nal preparations.  It is a, tolerably ener-
 getic  stimulant in doses of two drachms.
 Cadogan (Treat, on the gout) says that
 he has seen it produce unpleasant conse-
 quences when incautiously given, before
 the reduction of arterial excitement. The
 part used is the root, which  is sometimes
 a foot long and as'thick as the finger;  it
 is wrinkled, of a bright brown externally,
 and  yellowish  within.  Its odour  is very
 weak; its taste acrid and nauseous.  Ac-
 cording  to  M. Lassaigne  (Journ.  de
 Pharm.)  it contains  a great quantity  of
 ulmine.
   A.  rotunda.  Aristoloche  ronde,  Fr. ;
 Rundhohlwurzel, Germ.
   This is a  native of the southern parts
 of Europe, and  is identical in its proper-
 ties with the last mentioned species. The
 root is almost globular, heavy, compact,
 tuberous, brownish and somewhat wrin-
 kled externally, and  yellowish within.  It
 has a strong disagreeable smell when fresh,
 but becomes almost  inodorous when dry.
 The taste of the fresh root  is acrid and
 bitter, but is feeble  and nauseous in the
 dry state.
  A. trilobata.   Aristoloche trilobie, Fr.;
 Dreylapphohlwurz, Germ.
  A perennial plant, found in South Amer-
 ica and some of the West India  islands.
 This species has the  odour of the Prunus
 padus, and is said to be superior in medi-
 cal virtues to the Serpentaria.  Linn;eus
 speaks of it in his Materia Medica, as an
 excellent alexiteric  in the bite of  the vi-
 per.   The part employed  is  the  twigs.
 These, as found in  the shops, are long,
angular,  grooved, brittle, of a brown co-
lour, and about as thick as a straw.  They
have a strong smell of camphor, and a per-
manent, very bitter, aromatic but disagree-
able  taste.   The dose  is from  five  to
twenty grains.
  Besides those species which are offici-
nal, there are many others spoken of by
recent writers, and which require  notice.
   A. bilobata, a native of Brazil and the
 West Indies, is used as an emmenagogue,
 and its root is introduced into the vagina,
 to induce the expulsion of the foetus, when
 dead.  (Descourtils. Ft. Mid. des Antill.
 II. 5.)
   A. bracteata.  A native of India.   An
 infusion of the dried leaves is given by
 the Hindoo practitioners as an anthelmin-
 tic, in doses of Jii.  twice daily; and when
 fresh,  bruised  and  mixed with castor oil,
 they are used as an external application in
 obstinate psora. (Ainslie. Mat. bid. II. 5.)
   A. cordiflora.  This species bears flow-
 ers of an immense  size.   It is a native of
 Colombia.   The root is considered as an
 antidote against the bites of venomous
 snakes. (Humboldt. Nova Gen. II. 149.)
   A. foetida.  A native  of Mexico.  A de-
 coction of the root is much used as a wash
 in old ulcers. (Nova Gen. II. 147.)
   A. fragrantissima.   A native  of Peru,
 where it is  called  Bejuco de la estrella.
 The part employed in medicine is the
 bark.  This is  compact of an  ash-gray
 colour externally, and reddish within; of
 a camphorated odour, and a pungent  and
 aromatic taste.  It is much used in fevers,
 in scruple to half drachm doses. It is also
 employed as an emmenagogue  and alexi-
 teric. (Alibert.  Mat. Med. III.  71.)
   A. indica.  A native  of  India.  This is
 highly esteemed by the  Hindoos as an
 emmenagogue and anti-arthritic. (Ainslie.
 Mat. Ind. II. 5.) Thunberg says that a
 tincture  of the root is given in Ceylon as
 a stomachic and carminative.
   A. odoralissima.  This species is found
 in the  West Indies.  Ainslie states on
 the authority of Lunan (Horl. Jamaic.)
 that  it is a  most valuable alexipharmic,
and tonic.  Lamarck (Encyclop. Method.)
says that the juice has proved very effica-
 cious as a febrifuge.
   A. sempervirens.   A  native of Arabia,
where, according to Forskal, the leaves
are employed in wounds of the tendons
and bites of snakes.  In the latter case,
a decoction  of them with milk  must  also
be taken for some  time.  (Flora Egypt-
 arab. 157.)
  Bibliography.—Ainslie. Materia Indica. II.
 London, 1826.                        •
  Alibert.  Nouveaux Elimens de Tkirapeut.
 &c.  II.  Paris, 1806.
  Richard.   Elimens d'histoire naturelle.  I.
 Paris, 1831.
  Guibourt.   Histoire abrigie des drogues sim-
ples.  I.  Paris, 1826.
  Merat et De Lens.  Diet Univ. de Mat Med
 I.  Paris, 1829.
  Barton, (W. P. C.)  Veg.  Mat. U. S. II.  Phi-
 lada. 1818. 
244
ARM.  (Surg. Anat.)
  Bigelow.  Med. BoU U. S.  III.  Boston, 1820.
  Rafinesuue.  Med. Flora U. S.  I.  Philada.
1828.
  Smith, (D. B.)  Journ. Phil. Coll.  Pharm.  I.
262.  Philada. 1830.
  Kunth.  Synopsis Plant. Equinoc.  I.  Paris,
1822.
                      R. E. Griffith.
  ARM.  (Brachial region.)  In common
language,  the  term  arm is employed  to
designate the whole of the upper extremi-
ty ; but by the anatomist it is restricted to
that portion of the member comprised be-
tween the axilla and the elbow,—the other
portions being  denominated  fore-arm and
hand (q. v.).  Our observations will apply
to the arm considered in the  anatomical
sense.
  Art. I.   Surgical Anatomy.   The
length and thickness of the arm vary  in
different  individuals, and the  latter  is
greatly influenced by fortuitous circum-
stances.  In general, the humerus is about
one-fifth longer than the radius; but under
various modifications of development, these
relations may be materially changed. An
accidental interruption of the regular evo-
lution  of the one or the other bone, may
give rise  to a preponderance of length
and thickness  in  the other.  The entire
humerus may, indeed, from this cause, be
wholly  absent,—or  the  same  influence
may occasion a total  absence or  imperfect
development of either the radius or ulna,
or both,—the  humerus  being  perfectly
formed.  In the example of a Moor, whose
body was brought to our dissecting-room
a few years ago, the bones of both fore-
arms  were  not more than six inches in
length, although the humerus  was of its
natural size. Velpeau refers to a case, in
which the arm was shorter by one-fourth
than the fore-arm.   He also remarks, that
he had  seen two adults in whom the arm,
on one side, had ceased to grow at the age
of ten years, while  the other attained its
ordinary size. (Diet, de Mid. 2d edit. Art.
Bras.)   In the one case, the member wag
atrophied and  partially paralyzed; in the
other,  the fore-arm had been  amputated
below the elbow.  He infers that the ar-
rest of development was owing to an ob-
literation of the artery of the  arm, inas-
much  as, in  neither  instance,  could its
pulsations be perceived.
  Examined in its totality, the arm  may
be compared  to  a cylinder, slightly com-
pressed  upon  its  sides,  having several
elevations and depressions upon  its sur-
face.   The elevations  are occasioned by
the full and prominent bellies of the mus-
cles ;  the depressions mark the spaces be-
tween them.   Hence,  both are more con-
spicuous  in stout robust males>  in whom
the muscular system is strongly developed,
than  in females,  or those who are feeble
and emaciated.
St         ^fet
A* Deltoid.  B, Insertion of Deltoid. C, Biceps.  D, Triceps. E, Axilla. F, Situation of Inner Condyle of Humerus.
a, Skin on outer side of the Arm. b, Skin on inner side of tbe Arm. c, Cellular and Adipose Tissue,  d. Fascia.
I, Pectoraiis Major. 2, Coraco-brachialis. 3, Biceps.  4, Bracbialis Interims. 5, Latissimus Dorsi.  6. Teres Major. 7, Tri-
 ceps, Ions head. S, do. short head.  9, Brachial Artery.  10, External and Internal Collateral, Nutritious, and Anastomotic
 cus Major Arteries.  11, Basilic Vein. 12, Deep-seated Vein.  13, External Cutaneous Nenre.  14, Median Nerve.  15, In-
 ternal Cutaneous Nerves. 16, Ulnar Nerve.  17, Radial Nerve.
  The elevations are—first one  occupy-
ing the upper part of the arm, formed by
the deltoid muscle (A).   It  is broad  and
expanded above, where it forms the round-
ed  prominence  called  the  point  of the
shoulder.   It descends  about one-third
down the arm, and terminates in a narrow
point below, where it marks the attach-
ment of the deltoid  to the shaft of the hu-
merus (B).   When the arm is  elevated,
this prominence presents an anterior and
a  posterior border,  both  of which com 
ARM. (Surg. Anat.)
245
 inence at  its lower termination, and gra-
 dually diverge,—the first ranging oblique-
 ly  inwards,  in front of the  shoulder, to-
 wards the clavicle;  the second, obliquely
 backwards and  inwards, along the poste-
 rior boundary of the shoulder. Occupying
 the anterior aspect of the arm, and ranging
 in a perpendicular direction from the ax-
 illa to  the bend of the elbow,  there is a
 second prominence, occasioned  by the bi-
 ceps muscle (C). It is fullest at about the
 middle of the arm, and tapers towards its
 two extremities, the  upper of which is
 formed in part by  the coraco-brachialis
 muscle.  Posteriorly,  the fleshy mass of
 the triceps (D) forms a still larger promi-
 nence, which  extends  perpendicularly
 from the lower part of the neck of the
 scapula, to the  olecranon process of the
 ulna.   The arm likewise presents, at the
 elbow, an internal and an external lateral
 projection  of limited  extent, formed by
 the corresponding ridges of the humerus
 which lead to the condyles.
  On  the  inner and  outer  faces of the
 arm, on each side  of the bicipital promi-
 nence,  we have an elongated furrow or
 depression, ranging parallel with the axis
 of the arm.  The internal  bicipital fur-
 row commences in the axilla (E), and ex-
 tends to the inner condyle of the humerus
 (F), or rather to the bend of the arm.  It
 is bounded, in front at its upper part, by
 the coraco-brachialis—throughout the low-
 er  half of the arm, by the biceps;  poste-
 riorly, by the triceps, except near its ter-
 mination, where its boundary  is formed
 by the pronator radii teres.  It is traversed
 by  the brachial  artery and veins, the ba-
 silic vein, the median and ulnar nerves, and
 numerous lymphatics.  It is in this furrow
 that the artery has to be exposed when it
 becomes necessary to  secure it  by a liga-
 ture ; and it is owing to the presence of
 these vessels, that when this part of the
 arm is affected with inflammation, uneven
 indurated chords can be felt, running up-
 wards to the axilla.  The external bicipital
 furrow occupies the opposite face of the
 arm, and extends from the  axilla, where
 it commences immediately behind the at-
 tachment of the pectoraiis  major, to the
 elbow.  It is bounded  in front by the bi-
 ceps, and posteriorly by the triceps, ex-
 cept in the vicinity of the  elbow, where
 the long supinator intervenes between the
 furrow and the triceps,  and  forms its ex-
 ternal boundary.  At the bend of the arm,
 it unites with the  internal  furrow at an
acute angle, the space  between them be-
 ing occupied by the tendon of the biceps.
This furrow is traversed for some distance
                 21*
by the cephalic vein, and from the middle
of the member downwards, is occupied by
the  radial  nerve, which,  after  having
twined  around the posterior part of the
humerus to reach the anterior radial face
of the arm, follows it to the bend of the
elbow.  Following the anterior and pos-
terior margins of the deltoid,  there  are
two other furrows, which, as they advance
upwards, gradually recede from each other,
the one following the line of separation
between the deltoid and pectoraiis major,
—the other advancing backwards, to ter-
minate upon the dorsum of the scapula.
Where these furrows commence upon the
arm,  consequently where  the  deltoid is
attached to the  humerus,  no  muscle,  or
important vessel or nerve,  intervenes be-
tween the skin and the bone, which being
merely separated  by  cellular  tissue, this
point has been selected as the most eligi-
ble portion of the arm, for the insertion of
a seton, the establishment of an issue, and,
by many, for vaccination.
  The skin upon  the outer (a) and inner
(6) sides of the arm differs in some impor-
tant particulars.   On the whole of the in-
ner side of the member it  is remarkably
thin,  soft  and vascular, and is less firmly
united with the structures beneath, than
at any other point. Hence it glides with
greater facility,  takes on  inflammation
more readily, and is more prone to become
affected with  erysipelas.  It is likewise
more abundantly supplied with lymphatic
vessels, which circumstance, together with
its great tenuity,  increases its absorbent
faculties.  When  the lymphatics become
acutely inflamed, the great thinness of the
skin upon  this  portion of the  member,
shows these vessels ascending towards the
axilla, in form of delicate red lines.   On
the other portions of the member, the skin
is thicker, more compact in its  structure,
and  more abundantly supplied with seba-
ceous follicles. It is, therefore, more read-
ily affected with eruptive  diseases,  and
also with erysipelatous inflammation; but
is not so  liable  to be attacked with that
of a phlegmonoid character, as that of the
inner part of the member.  The skin upon
the whole circumference of the arm pos-
sesses great mobility, so. that  in ampu-
tations, and other operations, no difiiculty
is experienced  in  preserving  sufficient
flap;  yet  from  this very  circumstance,
great caution is requisite,  not to save
too  much skin,  as it will  be  very apt
to become  turned  inwards  upon  the
wound, and prevent union by the first in-
tention.
  The cellular and  adipose panicle (c) 
246
ARM. (Surg. Anat.)
which intervenes  between the  skin and
the muscles, varies in thickness, as well
as in texture, upon  different portions of
the arm.  Along the internal bicipital fur-
row it is abundant, and its meshes are re-
markably loose.   This character renders
it more prone than the cellular  tissue of
other parts of the arm, to become affected
with  phlegmonoid erysipelas, which fre-
quently  diffuses  itself along the  whole
length of the member, giving rise to an
extensive slough,  by which  the muscles
and  blood-vessels  are  not  unfrequently
laid  completely bare.   From the  same
cause, purulent deposits formed in this
situation, are seldom so narrowly circum-
scribed, as in other portions of the  mem-
ber; and very  often  the matter diffuses
itself extensively through the meshes of
the tissue, and involves the whole  inner
part  of  the  arm  in extensive suppura-
tion.  When,  moreover, the  artery  is
wounded, the blood may be driven exten-
sively through this tissue, and may occasion
either a diffused aneurism,  or an ecchy-
mosis of great  extent   Posteriorly and
externally, the tissue  is more dense and
resistant; hence, deposits of pus or blood
in these situations are generally circum-
scribed within narrower limits, and are
less apt to become  extensively diffused.
This  disposition  renders the tissue less
prone to become  involved  in  extensive
erysipelatous sloughing  than that  which
occupies the inner surface of the arm;  at
least when this form of inflammation at-
tacks these  portions of  the  member, it
does  not spread so readily, and is conse-
quently confined to smaller limits.
   The fascia of the arm (d), though at
some points consisting of little more than
a simple layer of cellular tissue, deserves
to be examined, since it has important re-
lations with the muscles and blood-vessels,
as  well as with  the  articulation  of  the
shoulder joint.   It may be considered as a
kind  of sheath, surrounding all the mus-
cles  and vessels,  and divided into a num-
ber of lesser sheaths or partitions,  there
being one for each of the parts  contained
within,  yet all intimately associated with
each other.  The first of these  secondary
sheaths is that which incloses the biceps
muscle.  If this  sheath  be  laid open in
front, and in the  direction  of the  length
of the  muscle,  by dissecting it outwards,
it will be found to pass  off from the cor-
responding edge of the biceps,  to become
attached to the external condyle and  the
 outer edge of the humerus, from the elbow
 upwards, as high as the attachment of the
 deltoid muscle.  Above that point it is re-
flected over the deltoid and pectoraiis ma-
jor, to form  a similar covering for them.
Cutting up its attachment from the outer
line of the  bone, it  can be traced back-
wards  upon  the triceps, where it is con-
tinuous with the  fascia of the posterior
face of the arm.   From the inner edge of
the biceps it passes off, in the inferior half
of the  arm, upon  the  arteries, veins  and
nerves, and divides into a number  of par-
titions, which, passing in their interstices,
form a sheath for each of them.  It then
attaches itself to the whole extent of the
inner line of the bone,  from the condyle
to the axilla.  In the  upper half of the
arm, however, the fascia, instead of pass-
ing directly from the biceps over the ves-
sels and nerves, is  first distributed over
the surface of the brachialis internus, be-
yond the  edge  of which, it pursues  the
same  arrangement as below.  In the ax-
illa, it loses itself in a bed of cellular tissue,
containing numerous  lymphatic  glands,
which, by extending upwards beneath the
pectoraiis minor muscle, and behind the
clavicle, serves  to associate the fascia of
the arm with that of the thorax and neck.
From the point at  which the fascia of the
arm is reflected  over the short head of the
biceps and the coraco-brachialis, it can be
traced upwards along those muscles, until
it loses itself in the capsular ligament of
the shoulder joint on  the one hand,  and
attaches itself, on the  other, to the cora-
coid process, and the lunated ligament by
which it is united  with the  anterior edge
of the  outer extremity of  the clavicle.
(Anatomical Investigations, by J. D. God-
man, M. D.   Philada. 1824.)  This latter
portion, spreading itself over the  surface
of the pectoraiis minor muscle, forms the
sheet of fascia which is perforated by the
cephalic vein, before  it unites with the
axillary.  A similar sheath  invests  the
brachialis internus, and attaches itself in
like  manner along  the inner and outer
margins of the humerus.
   On  the posterior  part of the arm, the
arrangement of the  fascia is more simple.
From the inner  and  outer margins of the
humerus, to which it is attached from the
condyles upwards, it glides  over the  sur-
face of the triceps  muscle, forming for it
a sheath,  simple at  its  lower part, but di-
vided above to adapt itself to the several
heads of the muscle.  One of these divi-
sions, following the  long head  of the  tri-
ceps,  becomes  attached to the  inferior
costa of the scapula, and continues with
the  aponeurosis which  invests the teres
minor and infraspinatus muscles.
   The muscles  of the arm exercise great 
ARM. (Surg. Anat.)
247
influence on operations practised upon it,
as well as on many of the accidents to
which it is exposed.   Those which arise
from  the scapula, and attach themselves
to the head of the  humerus, need not be
described, as they are more particularly
concerned in the mechanism of the shoul-
der joint; but the deltoid (A),  pectoraiis
major (1), latissimus  dorsi (5),  and teres
major (6), confined  to the upper third of
the member;  the biceps (3) and triceps
(7, 8), occupying its  whole length;  and
the coraco-brachialis (2) and brachialis in-
ternus (4),—the first  limited to the upper
half,—the  second to  the  lower—deserve
to be carefully noted.  The deltoid, from
the manner in which it acts upon the hu-
merus,  would naturally tend, when  that
bone  is fractured below the point of its
attachment to elevate the  upper frag-
ment, so as to allow the lower to glide be-
neath it were it not that its action is more
than counterbalanced, under such circum-
stances, by the pectoraiis major, latissimus
dorsi, and teres major, which draw the
broken bone towards the side of the body.
This  being  the case, the lower fragment
overlaps the upper  upon its outer side, in
which direction it is drawn by  the biceps
and other long muscles.   But should the
bone be broken through its surgical neck,
the same forces will give rise to a differ-
ent displacement.   The  pectoraiis  major
and latissimus dorsi  will then draw the
lower fragment towards  the side of the
body, while the upper, somewhat elevated
by the muscles inserted into the head of
the bone, will overlap it.  The  biceps, ex-
tending as it does the whole length of the
arm, without forming any attachment with
the humerus, exercises considerable influ-
ence  in  displacing  the bone when it be-
comes fractured,—a displacement which
could not be rendered considerable by the
sole action  of the  triceps and brachialis
internus, inasmuch  as the attachment of
those muscles to all the lower part of the
bone, would naturally tend to  resist  any
great overlapping of the fragments. These
same characters in the relations of the
long  muscles of the  arm, are moreover
important in connexion with the operation
of amputation.  The one being free, and
the others attached to the whole  length
of the bone, they will retract unequally
when divided,—the biceps undergoing this
change to a much greater extent than the
others.   The consequence of this will be
an irregular stump, unless the  precaution
be observed, to divide the biceps first and
after it has retracted  to the full extent to
divide the others on a level with it.  This
course should be  adopted, whether the
operation be performed by the circular in-
cision or double flap, since the disposition
of the structures of the arm is such, that
the flaps can scarcely be formed, except
from the anterior and posterior part of the
member; and as the biceps would retract
much more than  the triceps, the  flaps
would be of unequal  length.  (See  Arm,
Amputation of.)  The muscles near  the
shoulder joint likewise present an arrange-
ment which disposes them somewhat, when
divided  in  amputation by the circular in-
cision, to retract unequally, or at least in
such a manner, as to impart some inequal-
ity to the stump.   This  is more particu-
larly true of the pectoraiis major, latissi-
mus dorsi, teres major, and the long head
of the triceps (7).   Hence, many surgeons
have  condemned the performance of am-
putation at that point, except by the flap;
and some have even contended, that when
it becomes  necessary to amputate the arm
so high  up,  the operation should be prac-
tised at  the shoulder joint. There is, how-
ever, no valid reason  for the adoption  of
the latter procedure.
   The arm is  traversed along the whole
extent of its inner side, from the axilla to
the elbow joint by the brachial artery (9)
and its accompanying veins, all of which
are lodged  in the  bicipital furrow  or de-
pression of the member.  As the vessel
advances from above downwards, its course
is somewhat spiral, inasmuch  as where it
approaches the elbow, it gradually  winds
forwards to reach  the central portion of
the bend of the fore-arm.  Throughout its
entire course, it reposes so closely upon
the bone, that it can be easily commanded
by pressure; and  in  some cases of frac-
ture, it may be  lacerated  by the  sharp
fragments  of bone. In the upper third of
the arm, it courses along the inner margin
of the coraco-brachialis (2); but, from the
point at which that muscle is  attached to
the  humerus,  to  the elbow  joint,  it is
placed immediately on the inner side of
the biceps  (3).   In its whole extent, it is
enveloped  in a sheath  furnished by the
fascia of the arm, and is merely covered
by the skin, cellular tissue, and fascia.  It
is generally accompanied  by  two corre-
sponding   veins,   between  which  it  is
placed; and in the upper part of the arm,
the  median nerve (14) courses along  its
outer side, between  it  and  the  coraco-
brachialis muscle—sometimes  immediate-
ly in front; but lower down, the  nerve
crosses  obliquely  in  front  of  the artery,
and gets on the inner side of it.   High
up, the ulnar (16),  radial (17), and  inter- 
248
ARM. (Surg. Anat.)
nal cutaneous (15) nerves  are  likewise
placed upon its inner side, and in such in-
timate relationship, as to render it more
difficult to isolate the artery in that situa-
tion  than lower down, where  the  nerves
are further removed, in consequence  of
the manner  they  gradually recede  from
the vessel, to reach the  internal and pos-
terior parts of the arm.   The artery  may,
nevertheless,  be easily  exposed at any
point of its transit by conducting an inci-
sion along the inner margin of the coraco-
brachialis, in the upper third of the  arm,
and the border of the biceps in  the  infe-
rior two-thirds. Or, if the outline of these
muscles  should  not  be  well defined, the
incision may be made upon the course of
an imaginary line drawn  from  near the
middle of the axilla, to the middle of the
bend of the arm. High up, the median nerve
(14) must be turned outwards to  expose
the vessel; near the middle of the  arm,
it crosses the artery obliquely—generally
in front,  but sometimes  behind, and care
must be taken not to include it in the liga-
ture.  From this point to the bend of the
arm, it is situated on the inner side, and
must be  carried towards the internal part
of the arm, during the application of the
ligature.
   The other arteries of the arm are small,
and merely consist of branches of the bra-
chial.  They are the external and internal
collateral (10),  the nutritious,  and the
anastomoticus major (10). The first comes
off high up, and twines round the poste-
rior part of the  humerus to get  to the ra-
dial side of the  fore-arm, and anastomose
with the external recurrent.  The inter-
nal  collateral is smaller, and  takes  its
course towards  the internal  condyle, to
anastomose with the internal recurrents.
Both these vessels, as well as the anasto-
moticus major, are only important in es-
tablishing a free  collateral  circulation,
which serves to compensate for the oblite-
ration of the main trunk.  Hence,  after
the  operation for  aneurism, they become
so much dilated, as to be capable of trans-
mitting an adequate quantity of blood to
the  structures of the fore-arm and hand,
to maintain the  integrity of their vitality.
These vessels may,  moreover,  in conse-
quence of their  proximity to the bone, be-
come  pricked  or  lacerated  by spicuke
when the  humerus is fractured, and thus
give rise to considerable extravasation or
ecchymosis,—an accident which is pecu-
liarly  liable to  happen  to the  nutritious
branch, when the fracture takes place in
the vicinity of the point at which it pene-
trates the bone.
  The brachial artery presents many va-
rieties in its division and the order of its
distribution.  These, however, will be de-
scribed under the head  of Arteries, Spe-
cial Anatomy.
  The deep-seated veins of the arm (12),
generally two in number, though  some-
times there is only one, follow the course
of the artery, which is placed between,
and a little  behind, them.   In some  in-
stances, transverse branches pass from the
one to the other vein, in front of the ar-
tery, which are sometimes divided in cut-
ting down to secure the vessel, and bleed
so freely as  to  embarrass the operation.
The superficial veins, the basilic (11) and
cephalic, though not covered by any im-
portant structures, are contained within a
sheath or duplicature of the fascia of the
arm.  The first occupies the inner side of
the arm, but  is so far removed from the
artery, that it cannot be in the way of an
operation instituted for the purpose  of se-
curing that vessel. It sometimes continues
to the axilla as a single branch, but fre-
quently unites with the deep-seated veins
in the upper third of the arm.  The ce-
phalic mounts  from the bend of the arm
along the outer side of the member, until
it reaches its upper third,—then inclines
forward, and runs in the  space between
the deltoid and pectoraiis major, until it
reaches the axillary vein below the clavi-
cle, where it unites with that vessel.   It
is more  superficial than  the  basilic, and
can be easily discovered beneath the skin.
The  ancients  were  in the  practice  of
drawing blood from it, under  the impres-
sion,  that a direct derivation was thus
made from the head,  from which circum-
stance the vein received the name  which
is still applied to it.  Both superficial veins
sometimes become affected with phlebitis,
under which circumstance, they form two
solid  rounded chords, tender and  painful
to the touch, the course of which is marked
with  more or less redness of the superja-
cent skin.  They seldom become varicose
to any great extent;  yet Velpeau has re-
marked, that in two cases, he found them
so  much affected  in this way, that  at
times the  members  seemed to be trans-
formed into  erectile tissue, and the veins
were  covered  by   irregular  elevations
throughout their whole extent. (Diet, de
Med. 2d edit. V.  1833.)
   The lymphatics are likewise superficial
and deep-seated.  The  first are situated
between the skin and fascia, and when in-
flamed, their course is  accurately defined
by one or more irregular indurated chords,
the  course of which is frequently repre- 
ARM. (Surg. Pathol.)
249
 sented by a streaked redness,  and by ten-
 derness of the skin.  This condition is not
 unfrequently observed after the  operation
 of venesection, when  much inflammation
 supervenes, as well as in  those  cases in
 which abscesses and other diseases occupy
 Borne part of the member lower down.
   The integuments of the upper third of
 the arm receive a number  of nervous fila-
 ments from the intercostal nerves, and the
 whole length of the  region is  traversed
 by the cutaneous  and deep-seated nerves.
 The  first comprising the internal and ex-
 ternal cutaneous, and a small branch called
 cutaneous of Wrisberg, are destined  for
 the integuments of the arm and fore-arm.
 The  internal  cutaneous  (15)  descends
 along the inner side of the arm towards
 the internal condyle (F);—the  external
 (13) traverses the coraco-brachialis mus-
 cle (2),  to which  and the biceps it sends
 filaments, and descends to the correspond-
 ing portion of the opposite side of the arm.
 The cutaneous of Wrisberg is spent upon
 the integuments upon  the anterior and in-
 ternal part of the  member.  Most of their
 filaments are distributed superficially, and
 some  of them  occasionally become the
 seat  of  small  subcutaneous nervous  tu-
 mours, which are  exceedingly painful.
 The course of the median nerve (19), and
 its intimate relations with the brachial ar-
 tery, have  been already indicated.  The
 ulnar nerve (16), as it descends, gradually
 inclines backwards,  and recedes from the
 artery, to  pass behind the internal con-
 dyle, and between it and  the olecranon;
 while the  radial  (17)  twines round the
 posterior surface of the humerus, between
 two of the  heads of the triceps, to reach
 the radial  side  of the fore-arm.   In  its
 course, it sends numerous filaments to the
 neighbouring  muscles.  From the situa-
 tion of all these nerves, they are necessa-
 rdy much exposed to  injuries, which are
 always attended with a paralysis of the
 muscles  to which the injured nerve is dis-
 tributed.  Their proximity to the bone,
 moreover, exposes them, in a great degree,
 to  lacerations and contusions, from the
 sharp projections or spicules of the  frac-
 tured humerus,  and occasionally tetanus
 has been thus induced.  The same intimate
 relations sometimes occasion one or more
of them to become embedded in the mass
of new bone which forms around the point
of fracture.   An example of this kind, in
which the radial nerve became  thus en-
cased, has been reported by Manec.  (Bi-
bliotheque Mid.  I. 441. 1828. Velpeau.
Loc. Cit.)
  As  regards  the  humerus, much need
 not be said here.  Slender throughout the
 whole of its  shaft,  slightly flexed upon
 itself, and besides greatly exposed in con-
 sequence of the nature of its relations, to
 violence  from various sources,  it is re-
 markably liable to be fractured.  And it is
 somewhat curious, that of  all the cylin-
 drical bones,  it is one of those most lia-
 ble to become affected with necrosis, when
 seriously injured, as from gun-shot wounds,
 and other accidents of a similar character.
 Sometimes nearly the whole extent of the
 shaft is thus destroyed and converted  into
 a sequestrum,—the  strong and dense pe-
 riosteum which surrounds it, throwing out
 a thick layer of callus, which forms for
 the dead bone a  firm osseous casement.
   But from the  few muscles which  sur-
 round it, and especially from the  absence
 of any very large vessel  upon the poste-
 rior and external parts of the member,  it
 will always be easy to make an incision
 through the soft  parts, and after opening
 the incasement formed  by the new bony
 deposit, to extract the sequestrum. Indeed,
 should such a procedure become  necessa-
 ry, the entire bone might probably be re-
 moved in the same manner. (See Resec-
 tion.)  It should be remarked, moreover,
 that individuals who have lost a consider-
 able portion of the humerus, are still ca-
 pable of using the member with great ad-
 vantage.  Jules Cloquet has reported an
 interesting  case  illustrative of the truth
 of this assertion.  An individual who had
 lost the two upper thirds of the bone, was
 still capable  of using  the arm with con-
 siderable success.   Similar  cases have
 been observed by Yvan and  others.  (Diet.
 de Med. V. 580.)  The arm likewise often
 becomes  the  seat of false  articulations,
 consequent upon fractures improperly ad-
 justed or inadequately confined.  But it is
 fortunate,  that the  arrangement of the
 member is such, as to render it favourable
 for the  institution  of those procedures
 which are necessary for the radical cure
 of such accidents.        E. GEDniNGs.
   Art. II.  Surgical Pathology.  The
 arm, as a region, is subject  to a great va-
 riety  of lesions,  but  most of its  diseases
 and  accidents derive little  importance
 from their particular location, and the dis-
 cussion of them is therefore referred to the
 appropriate  general  articles, or to those
 which treat on the several tissues.  Inju-
 ries and changes of structure  seated in
 the neighbourhood of the  articulations of
 the os humeri  are attended with more pe-
culiar circumstances, and demand notice;
but these, together with the  surgical ana-
tomy of the parts involved, will be treated 
250
ARM. (Fractures.)
under the heads  of Shoulder and Elbow.
It  only remains for us  to  notice,  in
this place, 1. fractures, 2. amputation, 3.
resection of the body of the humerus, by
which we mean, that portion of the shaft
of the bone which lies between the upper
part of  the insertion of the pectoraiis ma-
jor and latissimus dorsi  muscles, and the
lower part of the origin of the brachialis
and the third head of the triceps, and 4.
aneurism and ligature of the  brachial ar-
tery.
   5 1. Fractures.  The frequency of these
accidents is  not so great as the exposed
situation of the arm would lead  us to ex-
pect.  The lightness of the member and
the  facility  of  its movements,  together
with the absence of the pressure  of super-
incumbent parts, more than  compensate
for the  extent of its  motion, and its con-
stant collisions with  surrounding bodies,
and render  it less liable to fracture than
the  inferior  extremity.  Some surgeons
are of a different opinion, but in the prac-
tice of out public institutions, fractures of
the leg  and thigh, as well as the clavicle,
are more frequently noticed than those of
the arm.
   The  varieties  in direction, extent and
location are  numerous.  The bending or
partial fracture of the arm, is indeed rare;
we have seen but two cases of this charac-
ter, occurring in young children.  In one
of these, the bone was curved very obvi-
ously, but not to any great extent.  It was
restored to its  proper  position without
completing  the fracture.   In the other
case, the deformity was more angular and
much more considerable.  The angle was
just below the insertion of the deltoid, and
the fracture was completed in the attempt
to reduce the limb.   As  often happens in
such  cases,  a slight  incurable deformity
was produced by the curvature of the ex-
tremities of the fragments.   (See Bones,
pathology of)
  1.  Longitudinal fractures sometimes
occur, but they are  generally connected
with  the  elbow joint (q- v.), and may be
therefore  regarded as extensions of frac-
ture of the condyles.   We have never met
with  any record  of longitudinal fracture
of the body of the bone not extending to
the joint and it may be proper to notice a
case which  came under  our care in the
Pennsylvania Hospital, in the year 1823.
A young carpenter who was standing near
a new building, with his  left hand on the
round of a ladder, received a  blow upon
the arm from a sharp spade which  fell
from the summit  of the wall.   The edge.
of the spade made an incision for nearly
its whole length near the outer margin of
the biceps muscle, wounding also the low-
er part of the deltoid;  and the corner of
the  blade striking the  os humeri about
three inches above the  external condyle,
separated a  fragment, four inches or more
in length, and in thickness equal to about
one-third  of the  diameter of the shaft,
from the outer and back part  of the body
of the bone.  The extent of the wound
was such that the fragment could be seen
and  felt. It was completely detached and
moveable;  but as its connexions with the
surrounding soft parts were but little dis-
turbed, and the periosteum was not abrad-
ed, it was suffered to remain in situ; ad-
hesive strips to the wound were employ-
ed, a roller was applied  to the whole limb,
and  the arm was confined on an angular
splint.  The wound healed by the first in-
tention, and the fragment was  reunited
without accident or deformity.
  2.  Oblique and  transverse fractures of
the  arm are common,  though we rarely
see any very great degree of obliquity in
these accidents.  It is by ho means neces-
sary to distinguish the  peculiar direction
of the fracture  in most cases, for reasons
which will be given when we consider the
character and causes  of the displacement:
indeed, much more mischief than benefit
results  from hypercritical researches on
this point.  If the obliquity is very consi-
derable, some peculiar precautions are re-
quired to secure the  accurate coaptation
of the fragments,  and to prevent the oc-
currence of a pseud-arthrosis; but in such
cases, the obliquity of the  fracture  is de-
tected, on the most superficial examination.
  Interlocking of the fragments from great
irregularity in the direction of the fracture,
is sometimes noticed,   and  may render
complete reduction difficult, or perhaps im-
possible ; but the deformity resulting from
this  cause is unimportant being confined
to a slight displacement in the direction of
the diameter of the bone, which is scarcely,
if at all, perceptible after the cure.
   The causes of fracture  of  the body of
the humerus, are generally such as act di-
rectly on the  part.   The  absence  of all
considerable curvatures in the bone, ren-
ders it little subject to  injury from  forces
acting through the medium of the fore-arm
or the trunk; in this respect it is strongly
distinguished from the os femoris.
  When the forces just  mentioned do pro-
duce fracture of  the humerus,  it takes
place almost  invariably about  the con-
dyles ; for the position of the head of the
bone is such, that the clavicle or some of
the processes of the scapula give way be- 
ARM. (Fractures.)
251
 fore the neck  or body of the humerus is
 endangered.
   Spontaneous fracture of the humerus
 from fragilitas ossium, cancer, &c, will be
 considered in the general article on Frac-
 tures.   But it is possible for the arm to be
 broken by muscular contraction alone.  An
 example of this last accident is recorded
 by Dr. Kirkbride, in the American Journ.
 Med. Sc. XVI. 33.; another was presented
 some years since in the Pennsylvania Hos-
 pital ; and  a third occurred in  the clinic
 of Mr. Guthrie, at Westminster Hospital,
 during the last  year.  (Lond. Med. and
 Surg. Journ. VII. 446. 1835.; also, Amer.
 Journ. Med. Sc. XVI.)  In  the two first
 cases there is every reason to believe that
 the  bones were healthy.  All the cases,
 but  the last recovered without accident,
 in the  usual time,  and all resulted from
 throwing very  small substances.
   Character and causes of displacement.
 In fractures of the  arm, the weight of the
 limb exerts considerable influence over
 the  displacement of the fragments.   It
 acts as a  perpetual  counter-extending
 force,  while the  patient  sits  or stands
 erect  and  thus  resists the tendency to
 longitudinal derangement; while it  not
 unfrequently becomes a cause of various
 angular deformities, during changes in the
 position of the patient  The muscles which
 lie lengthwise around  the bone, are  not
 very powerful  in their habitual contrac-
 tion, and when weakened, even by slight
 contusions,  are sometimes unable to sup-
 port the head of the bone in contact with
 the surface of the glenoid cavity.  In con-
 sequence of this laxity, there is little ten-
 dency to shortening of the limb from mus-
 cular contraction, even when the apposition
 of the extremities of the fragments is com-
 pletely destroyed by the accident.  Nor is
 it difficult to prevent the recurrence of
 shortening after  the  reduction,  except in
 the  rare cases of great obliquity in the
 fracture, for the  absence of considerable
 curvatures  in  the bone, and the  facility
 with which the general direction of the
 limb is preserved during the treatment,
 secure the constant apposition of the frac-
 tured extremities.  These remarks apply
 with most force to  fractures occurring at
 or below the insertion of the deltoid mus-
 cle.   In all this portion of the body of the
 bone, the muscles,  when not extensively
 injured, act the part of imperfect splints,
 and  limit more or  less the derangement
 which would otherwise  arise from the ac-
tion  of  the  deltoid  and  coraco-brachialis
muscles.
  Lateral displacements may occur in any
direction, but are seldom so extensive as
 to destroy entirely the apposition of the
 extremities of the fragments;  and angu-
 lar  derangements  equally  various  are
 very frequently observed.  The charac-
 ters of this kind of displacement whether
 caused by the weight of the limb and the
 motions  of the patient, or by the original
 forces producing the fracture, are so very
 uncertain  that they cannot be  reduced to
 regular  rules; but this circumstance is
 less regretted, because it neither obscures
 the diagnosis nor modifies the  treatment.
 Lateral  displacement from  muscular ac-
 tion is somewhat more important as it has
 a tendency to return after reduction, and
 may require, in certain cases, a slight mo-
 dification of the apparatus.
   As the nature of this species of displace-
 ment has been already mentioned in the ar-
 ticle on the Surgical Anatomy of the arm,
 p. 247, we shall add but a few remarks to
 those therein contained. When the fracture
 is seated within the attachments of the del-
 toid, this muscle acts upon both fragments
 at once, producing a tendency to angular
 deformity, outward,  or outward and for-
 ward, which  is controllable with  great
 ease;  but when it passes through the at-
 tachments of the teres major,  latissimus
 dorsi, and pectoraiis major, there is a much
 stronger disposition to angular deformity
 inward,  and one which is far less easily
 managed, because the superior fragment
 is short,  superficial, and covered by parts
 intolerant  of  much pressure.   Fracture
 in this situation is, however, comparative-
 ly rare.  In neither of the cases just men-
 tioned do we see  that partial or complete
 separation of the fragments which occurs
 when  the  bone is fractured  immediately
 below the insertions of the muscles.
   The last species  of displacement de-
 manding attention, is that produced by
 the  rotation of the lower upon the upper
 fragment, consequent upon changes of po-
 sition in  the fore-arm.  This displacement
 should never be neglected  during  the
 treatment, or considerable embarrassments
 to the motions of the limb may result from
 the reunion of the fragments in their mal-
 position.   The extent of the rotation can
 be readily ascertained at all times, by ob-
 serving the relative location of  the exter-
 nal condyle and the point of the acromion
 process of the scapula.
   The diagnosis of fracture of the body
 of the humerus is  extremely  clear.   It
 may be  generally detected at  a glance,
 unless when situated above the insertion
 of the deltoid.  The fore-arm hangs feebly
 by the side of the patient;  all attempts at
 voluntary flexion or extension,  are  pain-
ful, and extensive motions  of this charac- 
252
ARM. (Fractures.)
ter are commonly impossible;  unless the
fracture  is nearly transverse, or there  is
interlocking of the fragments.  Moreover,
the motions of the fore-arm, whether vo-
luntary or passive, instead of taking place
entirely at the elbow joint, are partly ac-
complished at the seat of the injury. The
deformity resulting from this cause is very
obvious when the  fracture  is  at or below
the insertion of the deltoid.  There is very
often a perceptible irregularity in the di-
rection of the arm, which changes its form
when the patient moves; and in all cases,
the surgeon can produce a bending of the
limb at the fractured part, by grasping the
superior part of the bone and gently mov-
ing the  elbow.  Sometimes there is very
obvious shortening of the limb produced
by the original fracturing force; and this
is a pretty sure indication that the fracture
is either comminuted or very oblique. Ex-
tension applied  to the  elbow or fore-arm,
readily reduces the  limb  to  its  natural
length and general form.  If it become
necessary to determine accurately the di-
rection of the fracture, this is readily done
by passing the fingers of one  hand along
the bone, from near the internal condyle
to the axilla, behind or within the inner
edges of the biceps  and coraco-brachialis
muscles, while those of the other explore
it along the outer side  of the biceps, and
the posterior margin of the deltoid.
   When the fracture occurs considerably
above the insertion of the last-named mus-
cle, somewhat more careful examination
is required;  but though the deformity of
the  limb is not always visible to the eye
at first  it cannot escape detection when
the  surgeon changes the  position of the
elbow, while his fingers are applied along
the bone in or near the axilla.
   These signs being  amply sufficient  to
determine the nature of the case, we can
scarcely express too strong reprobation of
the course pursued by many who consider
audible crepitation the  only sure test of
the existence ofa fracture.  That it gene-
rally occurs during the reduction of the
accidents of which we  are now treating,
is true;  but the attempt to produce it un-
necessarily,  as  a  means of diagnosis, is
cruel and unwarrantable.  The only cases
which justify the trial by crepitation, are
those in which the fracture is very oblique,
and the surgeon dreads that even after the
apparent reduction, some portion of muscle
or fascia may still be interposed between
the fragments, in such a manner as to en-'
danger the occurrence ofa pseud-arthrosis.
   Prognosis. Simple fractures of the arm
 generally unite with great facility.  The
ease with which the  fragments may be
kept in contact and  the  certainty with
which their malposition may be ascertain-
ed, whenever it occurs, render the patient
less liable to pseud-arthrosis, when treated
with ordinary skill, than in cases of frac-
tures of the thigh.  Comminuted fractures
usually recover without difficulty,  unless
the injury done to the soft parts is very
considerable.  When complicated with an
external wound the mechanical treatment
is often rendered difficult, but the result
is quite as favourable as  in fractures of
other bones.   Although the os humeri is
rather remarkably subject to necrosis from
constitutional  or  internal  causes,  and
though the parietes of the body of the
bone are dense and hard,  its proximity to
the centre of circulation, and the number
and activity of the vessels within and at
the extremities, render it less liable to
death from traumatic injuries and denuda-
tion of the periosteum.   Splinters which
retain  their connexion with the soft parts,
often reunite  with  great readiness,  and
the exfoliation that follows abrasion of the
■periosteum is generally superficial, unless
the denudation is quite extensive.  In sim-
ple cases, the new deposit generally ac-
quires considerable firmness in three or
four weeks,  according to  the  age  of the
patient; and the danger of deformity from
simple muscular action, is generally at an
end.   Still, the limb requires protection
from  all  accidents, and  cannot  be used
with safety for some time longer.  The
cure may be considered complete in five
or six weeks, when the patient is vigorous,
but all considerable exertions should be
avoided for a much  longer period.  Com-
plicated  cases  may require  months  for
their recovery. (See Art. Fractures.)
   Treatment.   We  might collect if it
were proper, a considerable variety of ap-
paratus  recommended at different times
for the treatment of fractures of the hu-
merus ; but as most of these machines are
either forgotten or  have  failed to obtain
general sanction, and as the more  impor-
tant of them are applied, with  some slight
modifications, in other fractures, we shall
avoid  needless repetition  and a vain dis-
play of learning, by neglecting those no
longer in use, and by referring to the ar-
ticles  on  Splints, and on Fractures of the
 Elbow, for a discussion of the merits of
several  others.  In  this place, we shall
confine ourselves to a description of what
is generally considered the best method
of treatment on this side the Atlantic.
   The indications in the mechanical treat-
 ment  of the simple  cases, are, 1st to re- 
                                ARM.  (Fractures.)                            253

 duce the fracture;  2d, to secure the limb  splints,  we  greatly  prefer the latter ar-
 against oedema, or other ill  consequences  rangement   It is also recommended that
 from the pressure of the requisite  dress-  two or  three  firm circular turns of the
 ings; 3d, to  secure the proper direction  roller should be placed immediately over
 of the  limb, by means of splints and com-  the site of fracture, to give additional se-
 presses which will prevent  all angular or  curity to the coaptation.   This, we think
 lateral derangements of the  fragments,  erroneous in  principle, and  injurious in
 from accidents or muscular contraction;  practice.  The tightness of these turns,
 and finally, to prevent deformity from ro-  if they are so applied as to accomplish
 tation,  and secure the perfect rest  of the  their  intention, is sufficient to embarrass
 parts,  by confining the fore-arm to the  the circulation in the veins and  lympha-
 trunk.                                    tics, and thus to thwart the main purpose
   To  reduce the  fracture, the patient  of the whole  bandage.   Moreover, there
 should be seated, if possible; the surgeon  is here no necessity for acting immediate-
 then brings the limb to its full length and  ly on the injured parts, (a necessity always
 position by grasping the elbow or fore-arm  to be regretted), in order to secure the pro-
 with one hand, so as to make extension,  per direction  of  the  fragments, except
 while,  with the fingers of the other,  he as-  when the fracture is located above the in-
 sures himself of the proper coaptation.  If  sertion of the deltoid; and when the short-
 considerable force be required, as is some-  ness of the superior fragment compels us
 times the case when there are great irre-  to resort to this  measure, it is better ac-
 gularities in  the  fractured  surfaces, it is  complished  by a  longitudinal splint, or
 more convenient to  flex the  fore-arm, and,  compress of moderate width, than by cir-
 giving the hand into the charge of  an as-  cular turns of a flexible roller.  Rejecting
 sistant, make pressure on the front of the  or adopting these directions, then, the sur-
 fore-arm near the elbow, to produce the  geon  carries the roller regularly up to the
 extension.                                shoulder, ascending by reverted turns over
   To secure  the  limb against cedema,  a  the deltoid; and  here it is decidedly bet-
 roller should now be applied, commencing  ter to secure the  first bandage, in prefer-
 pretty tightly, at the base of the fingers,  ence to reserving the surplus of the roller,
 applied neatly about the wrist, and ascend-  to descend with it, as some direct, over the
 ing by  reverted turns gradually less  firmly  remainder of  the apparatus;  which  can
 drawn, to the elbow. The fore-arm is then  never be done with neatness and security,
 placed  at right angles to the arm, with the  except,  perhaps,  in patients  very much
 elbow  carried to a  convenient distance  emaciated.   The superior part of this ban-
 from the side.   An intelligent assistant  dage  should be applied  as loosely  as is
 holding the wrist  of the patient with his  consistent with security, as there is almost
 left hand, continues gentle  extension on  always some swelling of the limb after its
 the  fore-arm  with his  right;  while an-  application.
 other, if the  fatigue or weakness of the    To fulfil the third indication, four splints,
 patient render it necessary,  effects  coun-  each about two inches in width, with round-
 ter-extension, by passing his arms  round  ed corners, are applied to the arm, in front,
 the chest and  interlocking his fingers over  in rear, and on each side. The inner splint,
 the  acromion of the injured side.   The  which is the  shortest, extends from the
 surgeon then proceeds  to envelope  the  axilla to within an inch and a half of the
 whole surface of the elbow with accurate  point of the internal  condyle, and should
 turns of the  roller, and causes them to  follow the interval between the  edge of
 ascend, but with still diminishing tight-  the triceps and the margins of the coraco-
 ness, to near the seat  of the  fracture,   brachialis- and biceps muscles.   This is
 Two directions of  surgical  writers, of   perhaps the most important of the splints,
 which we cannot entirely approve, require   acting most directly on the bone, and re-
 some notice at this stage of  the dressing,   quiring little or no graduation of the corn-
 It is  recommended  that  the inequalities   press applied beneath it.   It is  necessary
 of the limb should be filled with compress-   that this compress should  be flat,  and but
 es of cotton or other soft matter, before   little  yielding, or  it is very apt to arrest
 continuing the roller over them.  In very   the circulation in the brachial artery,—
 muscular subjects, this measure may be   one of the most troublesome difficulties in
 well employed about the insertion of the   these,  and certain  other fractures of the
deltoid,  when the fracture is  in another   superior  extremity.
situation; but as it is much more difficult     The outer splint extends from near the
to regulate the action of compresses con-   external  condyle, almost to the  acromion
fined by a roller, than those attached to   process.   Its compress must be graduated
  vol. ii.         22 
254
ARM. (Fractures.)
so as to fill the depression at the insertion
of the deltoid, and this part  of the  com-
press should be firm and unyielding when
the fracture occurs at or near this point;
but if the soft parts are much contused, it
may be so adjusted as to press with less
force on the immediate seat of the injury.
Much  pressure  immediately  on the con-
dyle should be likewise avoided.
  The  anterior  and posterior splints are
rather less important.  They may be di-
minished  in width when the limb is at-
tenuated ; but when the muscular develop-
ment is great  they  should  be of corre-
sponding dimensions, and their compresses
should be graduated (particularly the an-
terior one) to  suit the curvilinear form of
the limb.  There  is  an advantage in
making these compresses of more yield-
ing materials, as it gives a degree of elas-
ticity to the  apparatus without endanger-
ing the continued apposition  of the frag-
ments ; the tendency to displacement from
muscular contraction being mainly coun-
teracted by the other splints, because such
displacements are almost always either
outward or inward, and scarce ever occur
in the  antero-posterior direction.  These
splints extend from nearly the same height
with the outer splint  to the  bend of the
arm, and the olecranon, respectively.  One
of the  main points in the application of
this part of the apparatus, is to secure the
freedom of circulation in the brachial ar-
tery, which courses between  the anterior
and interior  splints.   We prefer, for the
lateral  splints, compresses formed of mus-
lin, graduated by being folded upon itself
lengthwise, the folds being made most nu-
merous where the greatest  thickness  is
required.   For  the anterior  and posterior
splints, we employ fine tow or hemp; and
all  the compresses are  secured to the
splints  by enveloping each set in a few
turns of  a roller.  A variety  of carved
wood,  or grooved tin splints, have been
recommended for the treatment of these
fractures; but nothing serves a better pur-
pose than that which is at once most sim-
ple and most accessible, namely, a com-
mon cedar shingle,  planed,  and cut into
slips  of suitable dimensions, with a  pen-
knife.
   When  the limb is  much attenuated, it
is sometimes inconvenient to apply four
splints; and when the fracture is seated
high up toward the axilla, the parts which
cover the superior fragment cannot always
tolerate the pressure of the internal splint.
In  both these cases,  the latter may be
omitted, and  a cuneiform graduated com-
press,  slightly thickened at  its superior
extremity,  and supported by a scapulary,
may be substituted for it.
  The splints being properly placed, and
secured for the moment by an  assistant,
the surgeon applies over them  a second
roller, commencing at the  elbow, and as-
cending, with occasional reverted turns if
the patient be muscular, to the  shoulder,
where he secures it with a pin, and gives
the roller in charge to  an assistant while
he  ascertains,  from the condition of the
thumb and  fingers,  that the  tightness of
the bandages does not occasion undue en-
gorgement.
  To fulfil the last indication, the  elbow
is brought  to  the  side,  the arm  being
slightly advanced; the  fore-arm is sus-
pended in  a sling, and the surgeon then
takes the remainder of the second roller,
carries it round the chest, beneath the ax-
illa of the  sound side, to near the elbow;
thence it is made to ascend by spiral turns
around  the chest, arm, and sling, to near
the shoulder;  and these turns are secured
by a double or single scapulary secured to
several of them both before and behind.
A third and broader roller  may be substi-
tuted,  often with  advantage, for the re-
mains of the  second bandage.
   The greatest disadvantage of this appa-
ratus is the liability of these long ban-
dages to stretch and become loosened; but
when  well applied, they do  not require
frequent alteration, and the trouble of two
or three reapplications  is amply remune-
rated by the  comfort  of the  patient, and
his freedom from the inconvenience oc-
casioned by the unequal pressure of straps
and other  evils attendant on the use of
more complex machines.  The  plan here
laid down,  is similar in its principal fea-
tures to that of Boyer (Mai. Chir. III.
190.):  the minuter  points  which  have
been added may  appear unimportant to
some,  but we feel confident that nothing
has been stated that does not deserve at-
tention.
   After the fifth week, in the adult it is
often convenient to remove the  apparatus
and to involve the arm in wet pasteboard
and a simple roller, the sling being still
continued.   In a week or two  more, all
treatment  may be discontinued, in most
cases.
   Fractures of the body of the humerus
complicated with  external wounds, may
require considerable modifications  of the
mechanical treatment, nor  would  it be
possible to  enumerate these.  The union
of the wound by the first intention  should
always be attempted, when not  obviously
impossible.  When this fails, it is often 
ARM. (Amputation.)
255
advisable, in bad cases, to place a carved,
or moulded pasteboard splint on  the un-
injured part of the arm, to secure this by
a Scultet bandage, and placing the patient
upon his back, to support  the whole limb
upon a pillow, with the fore-arm in semi-
flexion,  in an angular fracture-box.
  The accidental injuries  to vessels and
nerves in these fractures,  are  noticed in
the preceding article.  The other com-
plications, which are in no degree pecu-
liar to this region, will be  considered un-
der the  general head of Fractures.
                    Reynell Coates.
  5 2. Amputation of the Arm.  This be-
comes necessary, whenever a disease  or
accident  calling  for  the removal of the
member is situated so high up  as to ren-
der the  operation impracticable at the el-
bow joint.  It may be performed either by
the circular incision or the single or dou-
ble flap, and upon any part of the arm,
either above or below the  attachment  of
the deltoid muscle.   In all  cases, how-
ever, the limb should be amputated as low
down as  the  condition of the  parts will
admit, so as to secure to the individual all
the advantages afforded by a long stump.
  A.  Circular Incision.  This method of
amputating the arm, originally proposed
by Celsus, has been adopted, with Some
modifications, by a majority of surgeons,
since his time, and is still very extensively
employed.  Various modes of performing
it have been proposed, all of which will
be found to answer.
  a. Graefe's method. The patient may
be placed in a chair, or, as is recommend-
ed by Graefe, on a  convenient  table or
the edge of a  bed.   If the member is to
be removed below the insertion of the del-
toid muscle, the artery may be  command-
ed, either by pressure in the  axilla, or by
a tourniquet;  if above that point,  by pres-
sure upon the artery where it crosses the
first rib.   The arm should  be raised from
the side of the body, and inclined a little
forward, and  the elbow slightly flexed.
One assistant grasps the  member imme-
diately above the point at  which  it is to
be amputated, and draws the soft parts
forcibly upwards, taking care to increase
the traction while they are divided with
the knife, while  a second  supports it  at
the elbow.  The operator, placed on the
outside  of the member, and armed with a
common amputating  knife, makes a cir-
cular  incision through the integuments,
which being drawn  forcibly  upwards by
the assistant the muscles are next divided
by a bold circular cut carried down to the
bone, the  edge of the knife being at the
same time directed obliquely upwards, so
that while it revolves round the bone, it
will divide the parts in such a manner, as
to give to the face of the stump the char-
acter  of a hollow cone,  having its apex
directed upwards.  By adopting this pro-
cedure, there will be no necessity,  as has
been correctly  observed  by Guthrie,  to
dissect up the  integuments, inasmuch as
if the knife be directed obliquely, and the
assistant is  careful to make forcible trac-
tion of the  soft parts, an ample covering
can be obtained for the face of the  stump.
  In  consequence of the biceps muscle
being only attached by its  extremities, it
will sometimes retract, when divided, more
than the other muscles, and impart an ir-
regularity to the stump.   To  obviate this
difficulty, Samuel Cooper proposes to di-
vide it  simultaneously with  the  integu-
ments, by the first incision, so as to suffer
it to  retract before the  knife is carried
through the deep-seated muscles.
  Having divided all the parts completely
down to the bone, the retractor is to be
applied, so as to draw up and protect the
soft parts, and the bone is to be divided as
high up as  possible, by a few long and
regular strokes of the saw.
  The pressure being removed from the
arm,  the humeral artery,  which will  be
found on the inner side of  the bone, must
be tied, as well as any other vessels which
may  require the ligature.  The  stump
should then  be  carefully  sponged, the soft
parts drawn over the face of the stump
from each side, and approximated  in the
direction of a line extending from the an-
terior to the  posterior  part  of the  arm,
from  the lower  part of which the  liga-
tures should be allowed to hang.  Two or
three adhesive strips supported by a roller,
will be  sufficient to maintain  them  in
their situation,  and support the stump.
  In dividing the muscles in this opera-
tion, it is recommended by some surgeons,
to carry the knife in a perpendicular di-
rection down to the bone, instead of giving
it the oblique inclination recommended by
Graefe, and  while the assistant draws
the parts forcibly upwards, to insert the
knife a second time upon the cone formed
by the muscles, which adhere to the bone,
and divide  them by a second circular in-
cision.  This method will give to the face
of the stump the same  hollow or exca-
vated  character  which  is obtained by
Graefe's procedure,  and  will  likewise
furnish  a flap sufficiently large to cover
the bone.
  B.  With  a double flap.  The applica-
tion of the flap operation to  the arm, when 
256
ARM.  (Amputation.)
it becomes necessary to remove it  above
the insertion of the deltoid muscle, was
long since recommended  by Louis, Le-
blanc, Sabatier, and Trecourt, and has
been  applied in more modern times,  by
Klein, Langenbeck, and others, to those
cases in which  the operation is performed
at the usual point.
  a. Klein's method.  The arm  is support-
ed as  in the preceding operation, and the
artery commanded,  either by pressure or
the tourniquet.  The operator, placed  on
the outer side of the limb, and armed with
a double-edged  catlin, seizes the soft parts
upon the anterior part of the arm, between
the thumb and finger of his left hand, and
transfixes the member from without  in-
wards, making the point of the knife glide
round the bone, so as to come out opposite
to the point at which it entered.   Then
carrying it obliquely downwards and for-
wards, it  is brought out so as  to form  an
anterior flap of two and a half or three
inches in length.  By a similar manoeuvre,
a posterior flap  of the same dimensions is
formed, the member being  transfixed be-
hind the  bone, while the  soft parts  are
drawn backwards.   The  assistant  turns
back both flaps, and supports them while
the operator divides the remaining parts
down to the bone,  by a circular incision
carried round the member, on a level with
the base of the flaps.  This done, it only
remains to saw  the bone,  secure the arte-
ries, and  dress  the  stump, which is to be
done  in  the  manner already prescribed,
with  the  exception,  that  the  flaps  are
united from behind  forwards,  instead  of
from side  to side, so that the cicatrix will
be placed in a transverse direction.
  By  the  same method of operating, one
flap may be formed upon the inner, and
the other upon the outer side of the arm.
(Rust.)
  b. Langenbeck's  method. Langenbeck
makes an anterior and a posterior flap,  by
cutting  obliquely from the  surface to the
bone.   Everything  being disposed as di-
rected above,  an assistant  supports the
elbow, while the surgeon,  placed on the
outer side, for the left, and the inner, for
the right  arm,  grasps the member below
the point at which it is to be amputated,
and makes an incision in an oblique direc-
tion from without inwards,  and below up-
wards, terminating  at the  bone, so as to
form a flap of sufficient dimensions.  The
first incision  should be made posteriorly,
on the left, and anteriorly, on the right
arm.  A second  incision is next to be made
in the same manner, upon the opposite side
of the member, so as to form a second flap.
Both flaps  being  turned  back,  the  deep-
seated parts are divided  by a circular in-
cision, and the operation is completed in
the manner already described.
  By this  method, the arm  may be re-
moved with great celerity, but it possesses
no advantages over that of Klein, and can
not be so easily performed by  one  unac-
customed to the use of the knife.
  c. Louis's method.  In those cases  in
which  it becomes necessary  to amputate
above the attachment of  the deltoid mus-
cle, La Faye long ago maintained, that it
would  be better  to remove the member
at the shoulder joint, than to amputate
through the continuity of the  bone, be-
cause of the grea't liability of the pecto-
raiis major and other  muscles to contract,
and leave the bone naked, or the immo-
bility of  the stump, arising from the de-
struction of the principal muscles which
are inserted into it.  Larrey and Jobert
have also, in more  modern times, insisted
strenuously upon the propriety of adopting
the advice of La Faye ;  and even Guth-
rie affirms, that when the operation is per-
formed in this situation by the circular in-
cision, the bone  will  generally protrude
after a few dressings.  He nevertheless
recommends, that the  arm should be am-
putated immediately  below the tuberosi-
ties of the  humerus, in a manner present-
ly to be described.  Le  Blanc  warmly
contested the  propriety of the  advice of
La Faye, and notwithstanding the recent
authority of Larrey  and  Jobert in its
favour, few have admitted its  propriety.
The operation through the bone is less
formidable than that at the shoulder joint,
and the muscles which remain attached to
the head  of the humerus, will  impress
upon the  stump sufficient motion to render
it more or less useful to the individual.  It
was  to meet the difficulties  adverted  to
above, that the following method of ope-
rating was recommended by Louis, which
is likewise advised  by Sabatier.
  An assistant compresses the subclavian
artery where it passes over the first rib,
while a second supports the arm elevated
from the body, in  a  horizontal position.
The operator, standing on the  outer side
of the  member, makes a transverse  inci-
sion through the integuments and the an-
terior inferior part of  the deltoid  muscle,
from the  extremities of which, he extends
two others longitudinally, or rather some-
what obliquely, so as to form a trapezoid-
shaped flap, at the expense of the anterior
and external part  of  the muscle.  This
being dissected up and turned  back, the
remaining structures are  divided by a cir- 
ARM. (Amputation.)
257
cular incision down  to  the bone, after
which the latter is sawed in the usual
manner.
  d.  Guthrie's method.  Mr. Guthrie
prefers removing the member about an
inch, or an inch and a half, below the tu-
bercles of the humerus.   His method is
precisely  similar to  the oval operation
which will be described, for the  removal
of the arm at the shoulder joint
  The patient being seated, the artery is
to be compressed where it crosses the first
rib.   Two incisions, of a similar shape,
are to be commenced, one or two fingers'
breadth below the  acromion, as the case
may require; the point of the inner one,
instead of ceasing,  as in the operation of
the  shoulder, a  little below the  pectoral
muscle, is to be carried directly across the
under part, to meet the point of the outer
incision;  so  that the under part of the
arm is cut by a circular incision, the upper
in the same manner as in the operation at
the  shoulder.  These incisions are only
carried through the skin and cellular tis-
sue, which are at liberty  to retract but
are not to be turned up.   The deltoid and
pectoraiis major are then  to be  divided
close to the inner incision, and the oppo-
site portion of the  deltoid, on the outside,
with the  long head of the biceps, for the
extent of the outer incision.  A half-cir-
cular cut on the under part in the line of
the skin down to the bone, clears  it under-
neath, and  shows  the  artery retracting
with its  open mouth, which is at this mo-
ment advantageously pulled out  with the
tenaculum, and secured.  The flaps are
then to be turned back, and the bone saw-
ed,  after which, the vessels which may
bleed must be tied.   The flaps should be
brought  together so  as to bring the line.
of union  in a direction from above down-
wards.
   This operation is  well  suited to fulfil
the indications of the case, but we do not
perceive that it possesses any advantages
which may not be secured  either by the
operation with a double flap, or that by the
oblique circular incision, recommended by
Graefe, both of which  are more expedi-
tious, and easier of execution.  In a case
in which we had occasion, within a short
time, to  amputate the arm in the vicinity
of the shoulder joint, the  operation  was
performed in the following manner.  The
individual was brought to the edge of the
bed with his arm extended to a right an-
gle with the body.   The artery was com-
pressed by an assistant against the articu-
lation of the shoulder, the great elevation
of the clavicle, owing to the peculiar con-
formation  of the chest, rendering it diffi-
cult to compress  it  over  the first rib.
Standing on the outside of the member,
a long double-edged catlin was introduced
about the  middle of the deltoid muscle, a
little  below the acromion  process, and
thrust directly through, in  front of the
bone, so as to bring out its point in the
axilla, behind the fold formed by the pec-
toraiis major.   The instrument was then
made to cut itself out  by being carried
obliquely downwards,  and an anterior flap
was thus formed, comprising half the del-
toid and the outer portion of the pectoraiis
major.  The knife was next insinuated at
the same  point, and thrust through in the
same manner behind the  bone,  so that,
in cutting itself out a posterior flap of
similar form and dimensions was made,
consisting of the corresponding portion of
the deltoid, and the latissimus dorsi and
teres major. The flaps being turned back,
a circular sweep of the  knife  around  the
bone, divided  the  deep-seated structures,
and the operation was completed by saw-
ing the bone, securing the artery, and ad-
justing the flaps so as  to have their line of
union placed in a perpendicular direction.
Considerable embarrassment was experi-
enced in securing the artery, arising from
the retraction of the vessel  within  the
axilla, and its being  intimately surround-
ed by the nerves. Nearly the whole stump
united, however, by the first intention, and
none of the difficulties so much apprehend-
ed by surgeons were  experienced.
   C. Single flap.  Lowdham's method.
The  operation by the single flap has been
submitted to various  modifications.  The
following is the best method of performing
it, when the arm is to be amputated below
the attachment of the deltoid.  Everything
being properly disposed, the surgeon seizes
the anterior face  of  the arm, and inserts
the heel  of a common catlin upon the in-
ner part  of the member, which he then
conducts  across, in front, to the opposite
point on the outer side, making it describe
a slight curve with  its convexity down-
wards.  By this cut, the integuments upon
the anterior part  of the arm, and the bi-
ceps  muscle,  should  be divided down to
the bone.  The soft parts upon the poste-
rior part of the arm, including the triceps,
should next be grasped between the thumb
and fingers, and drawn backwards, while
the catlin, introduced at the angle of the
first  incision,  should transfix the member
behind the bone, and be brought out so as
to cut a flap of sufficient extent to cover
the face of the stump.
   This operation  is exceedingly simple, 
258                           ARM.  (Resection.)
 but in performing it, the biceps should al-
 ways be divided and suffered to  retract,
 before the  flap is  formed from the poste-
 rior part of the arm; otherwise, the stump
 will be uneven, and the bone will be apt
 to protrude.       ,       E. Geddings.
   | 3. Resection of the Humerus. It may
 become necessary, in consequence of ne-
 crosis and other conditions affecting the
 shaft of the humerus, to resort to the re-
 section of a portion of the bone, more or
 less considerable, according to the extent
 of the disease.  It  is  likewise often ne-
 cessary to practise the  same operation
 upon the extremities of the bone;  but the
 method of doing  this will be described
 under the heads of Resection of the elbow
 and shoulder joints.
   Operation.   When  it  becomes neces-
 sary to perform resection  of a portion of
 the shaft of the humerus, the arm should
 be  extended upon the  edge of a table, or
 supported  in a  horizontal position by as-
 sistants.  With a common scalpel or bis-
 toury, a longitudinal incision of sufficient
 length, should be made along the outer
 bicipital furrow of the arm, parallel with
 the axis of the member.   This should be
•carried successively through the skin, cel-
 lular and adipose tissue, and  fascia, until
 the bone is fully exposed to the extent re-
 quired.  In order to isolate  it from the
 surrounding muscles, the brachialis inter-
 nus must be first carefully dissected from
 it in front and the triceps behind, by car-
 rying the knife close to the shaft of the
 bone.   In  this stage of the operation, the
 branches of the external collateral artery
 will  be divided, and must be secured by
 the  ligature.   The radial nerve  which
 twines around  the  posterior  part of the
 humerus, to get upon its  outer and ante-
 rior face, must be carefully avoided; and
 in order to prevent  it from being injured,
 it should be cautiously isolated, and held to
 one side. The bone being thus exposed to
 the extent that may be desired, the resec-
 tion must be completed by sawing through
 the shaft above and below, while the edges
 of the wound are held asunder and protect-
 ed by means of a broad spatula.  This part
 of the operation can be best achieved with
 a chain saw;  but if that instrument is not
 at hand, a common Hey's saw will answer
 every purpose.  Some caution will be re-
 quisite in isolating the bone, not to injure
 the brachial artery, which, throughout a
 considerable extent of the arm,  reposes
 closely upon its inner and anterior surface.
   After ah the bleeding vessels have been
 secured, the  coagulated  blood should be
 sponged from  the wound, and a  pledget
of fine  lint interposed  between  its lips.
Over this, light dressings should be ap-
plied, and the limb  placed in an  easy
position, upon  a pillow.    The  general
treatment must be  conducted as directed
under the article Resection.
  In some instances, in consequence of
the violent contusions inflicted by gunshot
and other causes, nearly the whole extent
of the  humerus becomes  necrosed, and
must be removed.   Occasionally, indeed,
it has been thrown off by the spontaneous
efforts  of nature, and no  reproduction of
bone following, the whole extent of the
corresponding portion of the arm has re-
mained  perfectly flexible, and without any
bony shaft to sustain it.  We have seen a
case of this kind, in which the destruction
of several inches of the bone followed a
violent  contusion, and after becoming de-
tached from the living portion, was thrown
off through an  opening in the soft parts.
The arm, which remained flexible at the
point, dangled  by the side, but was, not-
withstanding, of great use  to the  indi-
vidual.   Jules  Cloquet presented an in-
dividual to the Academy of Medicine, who,
in the battle at  Fleurus, had two-thirds of
the humerus shot away. Some time after-
wards  the remainder of the  bone was
thrown  off in a state  of necrosis, and the
wound healed.  At the time he was sub-
mitted  to the  Academy,  the limb hung
only by the soft parts, yet  could be em-
ployed  to great advantage by the indivi-
dual. (Berard. Diet, de Mid. 2d edit. V.
592.)  Yvan remarked at the time, that
there were several  individuals at the H6-
tel  des  Invalides, in a  similar condition.
These facts render it probable, that should
the necessity occur, the whole of the hu-
merus might be removed by an operation.
                        E. Geddings.
  "> 4.  Aneurism and ligature of the bra-
chial Artery.   Every portion of the bra-
chial artery, from the axilla to its bifurca-
tion at  the bend of the arm, is liable to
aneurism; yet  in consequence of the fre-
quency  with  which it is punctured at the
latter point, in  the  operation  of venesec-
tion, aneurisms oftener form there, than
upon other portions  of the vessel.  As we
have separated the brachial region from
the  elbow,  it  does not fall  within the
scope of our present observations to con-
sider aneurisms at the bend of the arm;
we shall consequently  leave  them, to be
described in connexion with the region to
which they belong.
  Aneurism is  seldom developed upon the
course  of the brachial artery, except as
a consequence  of wounds, contusions, or 
ARM. (Aneurism of artery.)
259
violent strains affecting the part; and even
when extensive alterations of the coats
of the vessel exist  some such exciting
cause is generally necessary, to give rise
to the disease.  Such alterations are, in-
deed, of comparatively rare occurrence in
the brachial artery, and  very  few cases
have been reported,  in which, when they
did exist they were  followed by the spon-
taneous development of aneurism, without
the concurrence of more  or less violence
or force.   Hodgson  remarks, that he had
never witnessed such an  event.  Pelle-
tan reports a case,  in  which a large an-
eurism formed at the bend of the arm, in
consequence ofa diseased state of the ar-
tery,  the  coats of which  were  so much
altered, that hemorrhage took place after
the operation, and destroyed the patient.
Scarpa,  likewise, has referred to two
cases, on  the authority of Paletta and
Flajani.  In one of these, however, the
influence of force co-operated, the devel-
opment  of the tumour being induced  by
the artery giving way under the muscular
exertion required in  lifting a heavy body;
and in the other, it is probable some force
was employed, as the formation of the tu-
mour was preceded by a crack, as though
something  had  given  way in  the arm.
(Hodgson.  Traiti des maladies des ar-
teres et des veines: traduit par Breschet.
II.  142.   Paris, 1819.)
  Aneurism affecting the two upper thirds
of the brachial artery,  may be  either dif-
fused or circumscribed, according to  the
nature of its cause, or the period of its
duration.  As the vessel is superficial, and
not tied  down firmly  by aponeurosis  or
muscle, the  tumour is generally conspicu-
ous, and can be  easily recognized by its
pulsations, and other characters peculiar
to such affections. The same cause facili-
tates its diffusion and increase of size, and
the tumour is not flattened and compress-
ed,  as it is in some other regions.
  The termination of brachial  aneurism
presents nothing peculiar.  When left to
itself, its issue is the same as that of an-
eurisms in other portions  of the vascular
system, and is brought about by analogous
changes. In the treatment of the disease,
two procedures  may be adopted, which,
though they produce the same result ulti-
mately, accomplish it somewhat different-
ly.  The first effects the obliteration of the
aneurism by compression  made  upon the
course  of the artery: in  the second, the
obliteration  is accomplished by a ligature
applied to the vessel.
  How far compression should be relied
on as a means of curing aneurism of the
brachial artery, is a question not yet satis-
factorily decided.  The size and shape of
the member, the superficial situation of
the vessel, and the closeness of its rela-
tions with the bone through the whole of
its  transit, which furnishes a solid point
of resistance against which compression
may be advantageously made, are all cir-
cumstances highly favourable to the suc-
cess of this mode of practice. The course
of the  median  nerve along the front of  •
the artery may, however,  constitute  an
objection,  on account of the pain which
might be inflicted by  the long continuance
of the  pressure upon  it.   Although incon-
venience from  this cause is possible, we
do not think it  would be often realized,
—and  there are reasons  for believing,
that many cases of aneurism of the bra-
chial artery might be successfully treated
by  compression, thus rendering it unne-
cessary to resort to  a painful operation.
We are the more confirmed in this senti-
ment  by the fact, that several examples
of cure have been reported by authorities
entitled to full confidence,—and this suc-
cess has been  obtained,  as well in cases
of aneurismal varix  at the bend of  the
arm, following injuries received in vene-
section, as in  common  aneurism of  the
brachial artery.
   The means of making compression  are
so numerous and diversified as to render
it inexpedient  to enumerate or describe
them.  The object is to maintain an ade-
quate  degree of compression  upon  the
course of the main  trunk  of the artery,
without interfering with the collateral cir-
culation.   This cannot be done by a com-
press and  circular bandage, applied in  the
ordinary way, but may be  easily accom-
plished by any of the ordinary press arte-
ries, or by a slight modification of the or-
dinary tourniquet. The most simple instru-
ment of the first kind, applicable to the re-
gion under consideration, is a common elas-
tic steel spring of the requisite strength,
bent nearly  into the shape of the  letter
U, with a small pad attached to each  ex-
tremity. One of these pads should be fixed
upon the course of the artery; the other,
against the opposite  side of the member,
the spring  being so curved, that by its
elasticity,  it will tend to make the pads
approach each other.   The common tour-
niquet may be used  for the fulfilment of
the same  indication, if two short splints
be  provided, having  a  diameter  a little
greater than that of the arm.  A gradu-
ated compress should be laid over the  ar-
tery, upon which one of the splints is to
be placed longitudinally; the other should 
260
ARM. (Ligature of artery.)
be placed upon  the  opposite side of the
member, taking care to interpose a com-
press to protect the soft parts; and the
strap of the tourniquet should then  be
buckled around the whole,  so as to have
the screw over the outer splint.   A few
turns of the  instrument will be sufficient
to establish the requisite degree of com-
pression, which may be increased or di-
minished at pleasure.
   In recent diffused traumatic aneurism,
the  compression  may  be  made directly
over the wound; but in those of longer
standing, it will, in general, be better to
establish it a little above.  To insure suc-
cess, it will be necessary to call into requi-
sition the ordinary adjuvant treatment; as,
the application of ice  to the tumour,  a
strict antiphlogistic diet perfect quietude,
and  other means enumerated under  the
article Aneurism.  It is represented, that
by acting on these  principles, Winter
succeeded in curing a brachial aneurism
in the person of the Queen of Bavaria.
Flajani has also  reported examples of
success; and several cases of aneurismal
varix,  which were effectually cured by
this  procedure,  have been  published by
Brambilla (Act. Acad. Casar Joseph. I.),
Guattani  (De  spur,  brach.  Aneurism.
Hist. IV.), Monteggia (Instituzioni Chi-
rurg. I. 187.),  and others.  It is, more-
over, stated by Velpeau, that in the case
of an individual affected with four aneu-
risms of the arm, of a year's standing,
Lisfranc succeeded in arresting the pro-
gress of the  disease, by the laced stock-
ing.  (Mid. Operatoire.  I. 211.).   When
a cure  is effected by  this process,  it is
generally by  the obliteration of the arte-
ry. Yet the observations and experiments
of Winter, Jones, Wesling, Walther,
and Beclard, prove, that in some cases, a
cure is accomplished without the vessel
being closed. (Rust's Handbuch der Chi-
rurgie. II. 23.)
   The ligature is unquestionably the most
effectual means of curing aneurism of the
brachial artery, and it is that which is al-
most universally resorted  to.  Nor is its
application to this artery confined to the
treatment of aneurisms affecting it alone;
it is  also extended to cases of this disease
implicating the radial, ulnar, and interos-
seal  arteries,  high up in  the arm;  to
wounds of those vessels taking place in
the same situation, when the bleeding ori-
fice  itself cannot be  found, or the wound-
ed branch cannot  be  conveniently  ex-
posed ;  and,  likewise,  to  wounds of the
brachial artery itself.  We learn from the
records of the science, that the operation
was performed by some of the early sur-
geons ;  yet  it is  a little remarkable, that
even  so late as the  time of Heisteh,
Sharp, and Gooch, it was supposed, that
when an aneurism was cured by it, there
was a high  bifurcation of the artery into
its radial and ulnar branches, so that after
one of them was tied, the other remained
to carry on the circulation.  (Hodgson.
Loc. Cit.  139.)   Mollinelli and White
first pointed out  this error, and the cor-
rectness of their views  has  been  fully
proved by the investigations of more mo-
dern surgeons, and the brilliant triumphs
which the science has achieved since their
time.   It  is now well known,  that when
the trunk of the  artery is obliterated, the
collateral  circulation,  consisting  of the
free anastomoses between the superior
and inferior collateral,  the great  anasto-
motic, and the recurrent branches, is am-
ply sufficient to obviate any mischievous
consequences likely to arise from  the in-
terruption of the  main channel of the cir-
culation in  the arm.  It  is  exceedingly
rare for any bad effects  to arise from de-
fective  circulation in the fore-arm, when
the brachial is tied;  but by no means un-
common, when this operation is performed
for  the  cure of aneurism, for  the pulsa-
tions of the tumour to recur after a few
days,  in consequence  of its receiving a
supply of blood from below,  through the
anastomosing vessels.  This is indeed so
much the case, as to render it  necessary,
in some instances, especially in aneurisms
at the bend  of the arm, to adopt the me-
thod of Antyllus, and apply  a ligature
both above and below. (See Elbow.)
  Operation.   The  individual may be
placed  in either a recumbent or  sitting
posture.   In either case,  the arm  should
be  extended to  a right angle with the
body,  upon  a table,  and the hand placed
in supination.   The  operator, standing on
the outer side of the member, draws a
line from the middle of the axilla to the
central  point between the two condyles
of the humerus.  This line will represent
the course of the artery,  and will corre-
spond to the ulnar border of the  coraco-
brachialis muscle in  the upper half of the
arm, and to the margin of the biceps from
thence to the elbow.  He may also ascer-
tain the course of the artery by its pulsa-
tions, or,  in lean subjects, by feeling for
the median nerve, which, when the arm
is extended, will be felt beneath the skin,
ranging along the  internal bicipital fur-
row, in form of a  tense round chord, mark-
ing accurately the course of the  vessel.
If the artery  is  to be tied in  the upper 
ARM. (Ligature of artery.)—ARNICA.
261
third of the arm, with a common scalpel,
he makes an incision through the integu-
ments, two inches and a half or three
inches in length, extending  from above
downwards  on the right arm,  and vice
versa on  the  left, carrying  it along the
course of the line previously traced,  or,
what is the same thing, along the inner
border of the coraco-brachialis muscle.
Having exposed the sheath of the vessels,
the fore-arm should be slightly flexed, in
order to relax the parts, while an assistant,
with his fingers, or  with blunt  hooks,
draws the lips of the wound asunder.  A
small portion of the aponeuroses investing
the vessel should then be pinched up in
the bite  of the forceps, and  carefully di-
vided horizontally, so as fairly to open the
sheath.  By introducing the point of a
grooved  directory into this opening, the
sheath may be further divided, if neces-
sary, and the instrument carried beneath
the artery, isolating it at the same time
from the median nerve  and the accom-
panying veins, and elevating it slightly
from its bed.  A ligature conducted by
an aneurism  needle, can then be  passed
beneath the artery and tied.  As the me-
dian nerve, in the upper third of the arm,
is on the  radial side of the artery,  the
needle and ligature should be passed from
without  inwards, in  order  to  avoid  in-
cluding it with the vessel; and great care
will be requisite, to separate  the two  ac-
companying veins, one of which runs upon
each side of the artery, which is some-
times overlapped by them. The ulnar and
internal cutaneous nerves are on the ulnar
side of the vessel, and must likewise be
avoided.   As  they proceed  downwards,
they gradually recede, so as to be out of
the way of an operation  performed below
the  middle of the arm.  Should any em-
barrassment be experienced by the wound
becoming filled  with  blood,  it  can be
easily remedied,  by an assistant compress-
ing  the  artery above, while  another con-
stricts the  whole  circumference  of  the
limb below, so as to  interrupt the  course
of the venous circulation.
   When the artery  is to be tied  in  the
middle or the inferior third of the arm,
the  operation is performed  in the same
way, except that the incision is made along
the inner margin of the biceps muscle, in-
stead of that  of the coraco-brachialis, and
the  needle and  ligature are passed from
within outwards, on account of the nerve
being, in this part of the member, placed
upon the inner side of die \ essel.  Should
the. incision  fall  upon the point at which
the  nerve crosses the artery obliquely,
about the middle of the arm, greater cau-
tion will be requisite not to tie it up with
the vessel.   It Will likewise be  proper  in
all cases of high bifurcation of the artery,
to ascertain,  by making compression al-
ternately upon both branches, before the
ligature is applied, which  of them com-
municates with the aneurism  or wound.
  One end of the ligature should be cut
close  to the knot, and the lips  of the
wound, after it  has been sponged clean,
should be brought together  by adhesive
strips, supported  by a bandage, and the
case treated so as to  obtain union by the
first intention. A little coldness and numb-
ness of the  fore-arm  and hand are  gene-
rally experienced for some time after the
ligature is drawn, and the pulsation  in the
aneurism and at the  wrist ceases; but in
proportion as the collateral circulation be-
comes established, the  limb regains  its
warmth, and the pulsation at the wrist is
restored.                E. Geddings.
   ARNICA.  (Botany and Mat. Med.)
   Sex. Syst.  Syngenesia  Superflua. —
Nat.  Ord.  Compositae Corymbiferae.
   Gen. Ch.   Calyx with equal leaflets, in
a double row.   Seed-down hairy, sessile.
Seeds  both  of  the  disk and ray fur-
nished with seed-down. Receptacle hairy
Hayne.
   The generic character  of Arnica,  as
usually given in botanical works,  is not
accurate, and does not sufficiently distin-
guish this genus from Doronicum. Hayne
asserts that  the  two genera are distin-
guishable only by the circumstance, that
in Doronicum the seed of the ray is with-
out  pappus.   In both, the  receptacle is
hairy and not naked,  as commonly stated;
and  both  have imperfect stamens in the
ray florets.   The only species of Arnica
used  in medicine is the A. montana.
   A. montana.—Mountain arnica, Leop-
ard1s-bane. — Arnique, Fr.; Berg-Wol-
verly, gemeines dchtes  Fallkraut, Germ.
—Sp. Ch.  "Leaves  ovate,  entire; cau-
line twin, opposite."  Linn. Sp. Plant,  ed.
Willd.  The root of this  species of Ar-
nica is perennial, nearly horizontal, about
as thick as  a quill,  two or  three inches
long, abrupt, of a yellowish-brown colour
externally, yellowish-white internally, and
furnished with radicles rather lighter co-
loured  than  the  body of the root   The
stem is erect, round, hairy, from a foot to
eighteen inches high, sometimes simple,
sometimes furnished with one or two pairs
of opposite branches.  The leaves are ses-
sile, oblong  or  lanceolate, pubescent en-
tire, nerved.  The radical leaves, of which
there are from four to six, are from two to 
262
ARNICA.
four inches long, from half an inch to an
inch broad, obtuse,  and marked usually
with five nerves, rarely with seven; those
of the  stem are pointed,  and in one  or
two opposite pairs.  The flowers, which
appear from May to August are large, of
a beautiful golden yellow colour, and soli-
tary on the ends of the stem and branches.
The calyx consists of from twenty  to
twenty-four linear-lanceolate equal leaf-
lets, disposed in a double row, the exte-
rior being rough-haired, and brown at the
point.   The florets of the ray are  from
twelve to twenty, ligulate, striated, three-
toothed, and hairy at the  base ;  those of
the disk are numerous, funnel-shaped with
a  five-lobed  margin, and  rather  longer
than the leaflets of the calyx. The seeds
are slender, two  lines in length,  five-
sided, ofa dark-brown colour,  and crowned
with a simple, hairy pappus. Two vari-
eties of the plant are usually described;
—a. Alpina, with a simple one-flowered
stem and lanceolate leaves, and growing
in mountainous regions; and 8. Vallium,
somewhat branched,  with from three to
five flowers and oblong leaves, and some-
times occurring in lower situations.
   The mountain  arnica  is  a native  of
Europe and Asia, growing in  the northern
parts of those  continents, and found also
in the mountainous regions further to the
south.   It is said to be indigenous in the
higher latitudes of North America, west
of the Mississippi.  The root, herb, and
flowers (Radix, Herba, et Flores Arnica)
are designated as  officinal by most of the
European  authorities.   In  the  United
States Pharmacopoeia the whole plant  is
recognized under the officinal  name of
Arnica.  The flowers are thought to pos-
sess the peculiar virtues  of  the plant in
the highest degree, and are the part most
frequently employed.
   The roots  should  be  collected in the
spring, and quickly  but carefully dried.
In the process of drying, they shrink, be-
come wrinkled, and assume a darker brown
colour.  The  dried  leaves are of a pale
green colour,  particularly on the  under
surface; are thick; and have  a firm, some-
what coriaceous consistence.  Of the ./tow-
ers, those  only should be  collected which
are perfectly developed, and  free from in-
jury.  They should be gathered on a clear
day, and speedily dried.  They frequently
contain the eggs  and larva? of a certain
insect, which, according to  M. Mercier
of Rochefort, possess poisonous properties,
and, when swallowed with  the flowers,
are apt to produce a burning sensation  in
the throat and stomach, gastric spasm,
nausea, and vomiting.  Hence it was pro-
posed by Buchner, that,  in gathering the
flowers, the  florets only should  be pre-
served, while the calyx and receptacle
should be rejected, as the parts in which
the insects were most apt to be found.
But the  suspicion of their poisonous na-
ture has not been confirmed by subsequent
observation, and the  symptoms attributed
to them  are  such as the medicine  itself
not unfrequently occasions.   Besides, ac-
cording to GeigeR, the parts proposed to
be rejected are even more acrid and bitter
than the florets; and, as  the  observations
hitherto made in relation to the medicine
had  reference  to the whole flower,  it
would be improper to use portions of it in
the doses and mode ordinarily prescribed,
without further investigation.  It is de-
sirable, however, that the flower should
be kept  as free as possible  from  these
larvse; and it has, therefore, been recom-
mended to dry them by placing them, im-
mediately  after  collection,  upon seives
over a charcoal fire.   In the choice of the
dried flowers, those should be selected for
use which have the sensible properties of
colour, odour, and taste, in greatest per-
fection.
   It is said  that the Arnica flowers are
very apt to be  adulterated with those of
other plants,  particularly of different spe-
cies of Inula, and Doronicum, from which,
however, they may be  distinguished by
attention to  their odour and taste, and to
the characteristic form and  structure of
the different  parts composing them.  The
flowers of the  Doronicum Pardalianches
and scorpioides, which might most readily
be confounded with them, differ in having
no seed-down in the ray-florets.
   Sensible properties, and  composition.
The whole plant has a peculiar rather un-
pleasant aromatic odour, which is rendered
more obvious when it  is rubbed, and is
then apt to occasion sneezing.  The same
effect is produced by  the powder; and
this circumstance has probably given rise
to the name of tabac des Vosges by which
the  mountain  arnica is known  in  some
parts of France; though the origin of the
name has  also been  ascribed to a  fact
stated by M. Pomier, that the flowers are
apt during desiccation, to become  black,
exhale ammonia, and acquire the odour
of tobacco, as a substitute for which it is
asserted that the plant is smoked by the
peasants of the Pyrenees.   The taste of
arnica is acrid, aromatic, and bitter, and
continues long in the mouth. The flowers
are said to be more bitter than the leaves
or root.  The sensible properties and me- 
ARNICA.
263
dical virtues of the plant are extracted by
boiling water.
  The roots, according to Pfaff, contain
in 100 parts,  1.5 of volatile oil, 6.0 of an
acrid resin, 32.0 of extractive similar to
the variety of tannin which colours the
salts of iron  green, 9.0 of gum, and 51.2
of lignin.  In the flowers, MM. Cheval-
lier and Lassaigne found a resin having
the odour of the plant a bitter principle
analogous to that found by them in the
seeds of the Cytisus Laburnum and hence
named cytisin, gallic acid, a yellow colour-
ing principle, albumen, gum, and saline
substances.   The flowers contain also a
small proportion of volatile  oil, said to be
of a blue colour.   The bitter principle,
which might perhaps, with propriety, be
called  arnicin, is  yellow, of a bitter and
nauseous taste, deliquescent readily solu-
ble in water  and diluted alcohol, but with
difficulty in  strong  alcohol, and insoluble
in ether.  It is powerfully emetic and ca-
thartic in the dose of five  grains, and is
thought  to be the active principle of the
plant
  Effects upon the system, and therapeu-
tic  application.  Arnica appears to be a
general  stimulant, operating upon  the
functions both of organic  and animal life,
and at the  same  time producing  local
effects such  as  usually result from acrid
vegetable substances.   It does not how-
ever, give rise to that universal nervous
excitement which characterizes the ope-
ration  of the stimulant narcotics and an-
tispasmodics, as opium,  ether,  alcohol,
musk, &c.  According to Richter, it ex-
cites the irritability and  sensibility only
of the lower organic structures, in which
the lymphatics and  veins  predominate
over the arteries and nerves.  It operates,
therefore, he observes,  peculiarly  upon
the capillary vessels and the membranous
and fibrous tissues,  consequently upon the
aponeuroses,  the capsular ligaments, the
synovial membranes,  the periosteum, the
pleura,  the peritoneum, and the skin, ex-
alting   their  activity,  sometimes  even
arousing them from  deep inaction, and,
while  it thus  powerfully elevates the
whole vegetative or organic process, op-
posing the commencing extinction of ani-
mal life, as  exhibited  in the  colliquative
condition and the putrefactive tendency.
  The  observable  effects  of arnica are
the following.  In small doses, it promotes
absorption, and increases the  secretions,
particularly those of the skin, lungs, and
kidneys. More largely taken, it produces,
in addition, a strong irritative impression
on  the  alimentary canal,  evinced by a
feeling of weight and uneasiness in the
region of the  stomach, eructations, nau-
sea,  sometimes painful vomiting, griping
pain in the bowels, tenesmus, and dryish,
ineffectual alvine discharges. At the same
time, the pulse is increased in frequency
and  fullness,  and symptoms  of nervous
disorder make their appearance, such as
interior disquietude, anxiety, itching and
pain in the urethra, glans penis, and scro-
tum, sudden and convulsive movements
in different parts of the body as from elec-
trical shocks,  a feeling of constriction
about the diaphragm, difficult respiration,
a dry cough, and, in  consequence of the
propagation of action to the brain, pain in
the head, vertigo, and drowsiness. It was
first observed by Alex. Crichton, and the
observation has subsequently  been  con-
firmed by the experience  of others, that
the use of arnica serves to indicate  the
parts of the body which may be the seat
of disease,  particularly when  resulting
from external violence, by the  increased
sensibility  and even  pain which it occa-
sions in them.   All the effects abovo- enu-
merated are not experienced by every in-
dividual to whom the medicine is admin-
istered ;  and  the system  so readily  be-
comes habituated to it that after a short
time, it ceases, if moderately used, to ope-
rate disagreeably.  In over-doses, arnica
is capable  of doing much harm, and may
even endanger life.  Hence some caution
is requisite in relation to the quantity ad-
ministered ; and Richter observes, that in
small doses it is capable of fulfilling all
the indications for which it is given, while
nothing is gained by greatly  increasing
them.   The best antidote to its poisonous
operation is stated  by Hahnemann to be
vinegar.
  From what  has been said, it may be in-
ferred, that arnica is adapted to the treat-
ment of diseases in which there is a de-
ficiency of vital power or action, whether
general or local, as evinced by diminished
sensibility,  by a feeble circulation, by in-
activity of the  secretory organs, by ob-
structions and accumulations of all kinds
resulting from deficient absorption, and by
a tendency to decomposition and mortifica-
tion.  On  the contrary,  its use would be
hazardous  in cases of much general  ex-
citement, or of acute and active local in-
flammation, especially of  the  brain and
alimentary mucous  membrane;  and it is
necessary to be on our guard  against its
injurious operation upon the stomach and
bowels, even when these are in a healthy
state at the time of its employment.
  The medicine does not appear to have 
264
ARNICA.
been known to  the  ancients; and Mat-
thiole was probably wrong in his idea
that it was identical with the aXtsua of
Dioscorides ; as,  according to the flora
Grceca of Sibthorp, the plant is not to
be found in Greece.  (Merat et De Lens.
Diet, de Mat. Med.  I. 420.)  It is known
to have been employed in Europe  so early
as in the sixteenth century; and since the
publication of the work of Collin  in 1773,
has attracted much attention, particularly
among the German  physicians.   In Eng-
land and France it is at present not very
extensively used, and in the United States
stUl less; but the confidence reposed in it
by the practitioners  of Germany, and the
high strains of eulogy  in which it is
spoken of by the most enlightened medi-
cal authors of that  country, entitle it to
our respectful notice, even though we may
be disposed to pronounce their praises ex-
travagant  Perhaps  the chief reason why
the medicine is  not  more highly  appreci-
ated and  more  extensively used in  this
country, is the inferior quality of  the par-
cels found in our shops, resulting from the
deteriorating agency of time.  For  the
following account of the  complaints in
which  it is  employed by  the Germans,
the author is indebted chiefly to Richter,
in  whose work  on  Materia Medica  the
subject is well and amply treated.
  Perhaps  the most useful practical ap-
plication of the  medicine is to the treat-
ment of the different  forms of fever in
which the typhoid condition exhibits itself.
When,  in  these complaints, the  patient
falls into a state  of mental indifference or
prostration,  with  diminished sensibility
and a disposition to sleep; when the pulse
is soft and feeble, the vision dull, the eyes
turbid, the  teeth,  lips, and tongue,  en-
crusted with sordes,  the  skin  bathed in a
cold clammy sweat or marked with pete-
chias ; in  fine, when the  evidences  are
presented of a general failure of the vital
powers;  arnica  is habitually resorted  to,
and, as is asserted, with the effect of sup-
porting  the energies of the system,  and
favouring the resolution of the disease. It
is, however, almost always, in such cases,
given in combination with  the diffusible
stimulants  or antispasmodics, such as va-
lerian, camphor, ether, musk, &c., which
are more powerful  than arnica in their in-
fluence over the nervous system. Voigtel
prefers the root in  typhus fever, and con-
siders it as peculiarly applicable to cases
of great sluggishness of the abdominal
viscera, indicated by  tympanitic swellings,
looseness of the bowels, fetid discharges
of air, eructations, and a sense of weight
and fullness in the belly. He connects its
use with that of spirituous embrocations,
spice poultices to the abdomen, volatile
stimulants  internally, and Peruvian bark.
Stoll also particularly recommends the
root in the symptomatic and colliquative
diarrhoea of low forms of fever.
  In the gangrenous tendency  or condi-
tion, whether attendants upon fever or
occurring  in other  affections,  arnica is
highly esteemed; and it is said to be given
advantageously in small-pox, measles, and
scarlet fever, when these diseases assume
the putrid character, or exhibit a high de-
gree of nervous prostration.
  Even in  intermittent fever it has occa-
sionally been found successful, and is  par-
ticularly recommended in cases of long
duration, complicated with a peculiar mor-
bid condition of the nervous system, slug-
gishness of the  abdominal  viscera,  en-
larged and indurated spleen,  and cedoma-
tous swellings of  the belly and  lower ex-
tremities.   It  is also applicable to inter-
mittents of a typhoid or malignant char-
acter, and in these may be advantageously
associated  with bark.   Fifteen grains of
the powdered flowers,  or from one to two
drachms in the form of infusion, are given
every hour during the apyrexia. The root
is preferred when the complaint is  asso-
ciated  with diarrhoea.
  In the phlegmasia?, arnica can be safely
resorted  to only  when they are compli-
cated with  a prostrate  or  typhoid condi-
tion of the system, have  terminated in
gangrene,   or have assumed  a chronic
form.  Richter has employed it with dis-
tinguished success, combined with seneka,
in the latter stages of peripneumony, when
a  universal torpid condition existed in
connexion with a scanty, difficult and vis-
cid expectoration; and Hufeland found
it very useful in  the same complaint in
the  forms  which  he  designates by the
terms  notha, nervosa,  and putrida.  In
dysentery  it was  employed  successfully
by Stoll, Collin, and Hahnemann;  ana
it has been recommended in  gout  and
rheumatism; but it is obviously inapplica-
ble to  the  ordinary acute forms of these
complaints.
  As a remedy in the different hemor-
rhages, arnica  has also found eulogists;
and  it may have done good in the purely
passive form of  these diseases;  but as
they ordinarily appear, it would probably
be productive only of mischief.
  To the feeble forms  of dropsy, and to
all cases of extravasation either sanguine-
ous or lymphatic,  it would appear to be
adapted by  its property of promoting ab- 
ARNICA.
265
 sorption, and in the latter affections it is
 considered as one of the most effectual
 remedies.  It is possible that in this way
 it may have proved useful in obviating the
 effects of falls, blows upon the head, and
 other external violence, in  the  treatment
 of which  it has for a long time  enjoyed
 much reputation both  as an internal and
 external remedy, so as  to have acquired
 among the Germans the popular name of
 Fallkraut, and with  the learned  that of
 panacea lapsorum.  By  promoting the ab-
 sorption of fluids effused within the cra-
 nium or spinal canal, it may tend to re-
 lieve the paralysis occasioned by the pres-
 sure  of these fluids upon the  brain and
 spinal marrow, and by a similar operation
 upon effusions exterior  to these cavities,
 may, in some measure, remedy  those em-
 barrassments  in particular parts resulting
 from pressure upon the nerves which sup-
 ply them.
   As a remedy in epilepsy and  other con-
 vulsive and spasmodic diseases, it has been
 abundantly lauded ; and may have proved
 serviceable in cases dependent on general
 nervous debility, or disturbance in the
 stomach and  bowels,  or, as in some in-
 stances of epilepsy, upon bloody, purulent,
 or  serous  collections within the cranium
 or spinal canal.
   In  paralytic  affections it has acquired
 great credit; but according to Richter,
 is applicable  only to such cases as have
 their origin in organic lesions.   It has be-
 fore been stated, that arnica is thought to
 have been found especially useful in that
 paralytic condition both of the external
 and internal parts of the body which fol-
 lows  violent bruises  and concussions.   It
 has also been  used in hemiplegia succeed-
 ing apoplexy, in paraplegia, and in the
 various partial palsies proceeding from le-
 sions of the spinal marrow or nervous tex-
 tures of the abdomen.  It has shown itself
 peculiarly serviceable in palsy of the blad-
 der and lower extremities.  Numerous
 cases are recorded of its successful  em-
 ployment in  amaurosis,  and  Hufeland
 found it effectual in the cure of  a case of
 deafness.  Richter states that much good
 can be expected from it only  in recent
 cases of palsy, and that  in such as are of
 long duration it generally fails.  Thus he
 observes,  that  in the  palsies  consequent
 upon  apoplexy,  it must  be given  within
 the first six weeks  in order  to produce
 any good effect
  Finally,  according  to  Richter, some
good may be expected  from arnica in all
possible forms of disease, in which there
is a call for a strong  excitement of the
   vol. n.         23
 lymphatics, and an elevation of the nerv-
 ous and  vascular  activity in structures
 more  especially devoted to the functions
 of organic life; consequently in all kinds
 of glandular swellings, and the atrophies
 and 6cirrhosities of the liver, spleen, and
 lungs, dependent thereon; in blenorrhoeas
 of every  kind; in  chronic humoral asth-
 ma ; in chronic diarrhoeas whether atonic
 or colliquative; in old catarrhs;  in high
 grades of hypochondriasis, hysteria, jaun-
 dice, &c.  To these complaints it will al-
 ways be more or less applicable, according
 as the system at large,  or the diseased
 parts in particular, shall  be more or less
 deficient  in  vital  power and reaction.
 Kausch  considers it  the most effectual
 remedy for the ague-cake.  Hahnemann
 praises it highly in habitual dizziness with
 constipation;   Mursinna,  in  a sluggish
 state of the bowels with tenesmus; and
 Weickard, in the exhausting diarrhoeas
 arising from relaxation.  It may be tried
 in habitual vomiting  from atony of the
 stomach,  and often affords relief in the
 colliquative diarrhoeas of phthisis.
   In the above account of the practical
 application  of arnica,  it has been  the ob-
 ject of the author to present the views of
 the German physicians, whose high opinion
 of the remedy, founded on much experi-
 ence, may possibly lead to a more exten-
 sive trial of  its powers by the  medical
 practitioners of this country.
   Dose and mode of administration.  In
 all chronic  complaints, it  is proper to be-
 gin with a small  dose of the medicine,
 and gradually to increase it till some posi-
 tive effects are experienced.   In typhus
 fever and other acute  diseases, good can
 be expected only from large doses at once.
 It  may be given in powder,  infusion, or
 decoction.  The  dose  of the  powder is
 from five to ten or twenty grains, which
 may be administered with syrup or honey,
 in  the form of an  electuary.   The infu-
 sion, which is usually  preferred, may be
 prepared in the proportion of from one to
 four drachms to half a pint of  boiling wa-
 ter, and the whole may be given  in the
 course of twenty-four hours. The infusion
 of the  flowers should always be strained
 through fine linen, in  order to separate
 the small fibres which might otherwise
 irritate the throat.   Slight boiling renders
 the preparation more  efficacious by en-
 abling  the water more thoroughly to ex-
 tract the  active principles.   An extract
and tincture of arnica are directed by
 some  of the  European Pharmacopoeias.
The dose of the former is  from five  to
fifteen  grains; that of the latter, made in 
^266                         AROMAT.—ARROW.
the proportion of one ounce and a half of
the flowers to a pound of rectified spirit
is from fifteen to thirty drops several times
a day.
  Arnica  is  employed externally  in the
form of poultice, and of embrocation with
the decoction or tincture.  The powder
is sometimes sprinkled on mortified parts.
The remedy is also used by way of enema
in typhoid complaints and asphyxias.
                      Geo. B. Wood.
  AROMATICS.  The substances form-
ing  this class of  medicinal  agents  all
belong to the order of stimulants or ex-
citants, and are characterized  by a mild
and fragrant  or strong and pungent odour,
and  a warm  or  acrid taste.  Boerhaave
and  the earlier chemists  supposed that
these qualities were dependent on  a pe-
culiar principle inherent in certain bodies,
and  which could be readily obtained in
an  isolated  state;  but recent  and  more
extended  researches have demonstrated,
that they are common to a great  variety
of dissimilar  bodies.  In  the  vegetable
kingdom, aroma is in most cases owing to
the presence of volatile oil (q. v.), and al-
most every stimulant plant yields  this in
greater or less abundance,  and when iso-
lated from the other principles which ac-
company it, it will be found to produce all
the exciting  effects  of the entire vegeta-
ble in an increased degree.  This is pe-
culiarly the case in certain natural orders
of plants, as  the Labiatea?, Laurineae, &c.
This essential oil is in  some  cases con-
tained in glands visible to the  naked eye,
whilst in others it  is  so intimately com-
bined with other principles as  to be sepa-
rated only by long  and tedious processes.
   In some substances, as musk, bitter al-
monds, &c,  it has  been  shown by  Robi-
quet  that the  aroma is not exclusively
owing to the volatilization of the  volatile
oil or even of particles of the  body  itself,
but requires the presence  of ammonia to
develope  its  peculiar properties.  Accord-
 ing to the same chemist the aroma  of the
 Crucifereae depends, in all probability, on
the union of some volatile principle with
sulphur.  In fact, as has been observed by
 Ratier (Diet.  Prat),  the odour of aro-
 matic substances most frequently depends
 on the presence of a volatile body, but in
 other cases arises from new combinations
 of their principles  with certain bodies, by
 which they acquire odorous properties.
   The aromatic principle is  sometimes
 found in all parts of a plant, as in the La-
 biateae; in others it resides almost exclu-
 sively in the root,  as  in the Scitamineae,
 whilst, in the Umbellifereee, the seeds are,
in general, most strongly imbued with it;
and again, in some few species, the flow-
ers, or only their most delicate parts, as
the stigmas, contain this principle.  It is
often  in  intimate combination with some
other peculiar bodies, as  in the resins, in
musk, &c, and  is sometimes modified by
the presence  of other active constituents;
thus,  in  the  shaddock,  the most intense
bitter is  united to the  fragrant odour pe-
culiar to the Aurantiaceae.
  Aromatic substances  are stimulating
and tonic, and have been variously classed
as carminatives,  aphrodisiacs,  antispas-
modics, &c. (q. v.).  Their most general
use is as  condiments,  to  increase  the
flavour of food and to  aid  the  digestive
process by the  transient excitement they
produce  in the  stomach; for this purpose
they are in general use in all warm cli-
mates, where  their employment would
appear to be almost indispensable  to re-
store  the tone of the system exhausted by
the effects of the high temperature.
  As medicinal agents, the  use  of aro-
matics is indicated in cases  of atony of
the digestive organs where there is an
absence  of all symptoms of irritation and
inflammation.  They are also habitually
employed to disguise  the  nauseous taste
or smell  of many remedial articles.
                      R. E. Griffith.
  ARROW-ROOT. —Maranta, Ph. U.
S. — Arrow-root, Fr.  ;  Amerikanisches
Starkmehl, Arrowmehl, Germ.
   This name was originally applied to a
variety of starch procured from the roots
of different species of Maranta, particu-
larly the M.  arundinacea, an herbaceous
perennial plant, growing spontaneously in
the warmer latitudes of America, and cul-
tivated  abundantly in the West Indies.
(See Maranta.)  Similar products, derived
from various  other sources, have  subse-
quently  come  into use, under the same
name. Thus, a fecula is prepared in South
America and the West Indies, from the
root of the cassava plant, Jatropha Mani-
hot,  which is  sold as arrow-root both in
Europe and this country.  In  the East In-
dies, particularly in Travancore, upon the
 Malabar Coast,  an excellent  variety of
 arrow-root is said to be prepared from the
 root  of the Curcuma angustifolia, which
 has become a considerable object of trade,
 and is highly valued in England. (Ainslie.
 Materia Indica.  I. 19.)  Within a few
 years, a fecula has been imported  from
 the Sandwich  Islands, and sold  as  arrow-
 root  in  the shops, which is probably pro-
 cured from the root of the Tacca pinnati-
 fida, a native  of Tahiti and other islands 
ARROW-ROOT.—ARSENIC.
267
 of the South Pacific.  Finally, very pure
 potato starch has lately been substituted,
 to a considerable extent,  for  the product
 of the Maranta, under the name of potato
 arrow-root  All these varieties of fecula,
 when carefully prepared, are essentially
 the  same in chemical composition and
 medicinal properties; but close examina-
 tion  has detected slight differences  be-
 tween them, and, as ordinarily kept in the
 shops, they are  apt  to retain, to a certain
 extent, the flavour  of  the several plants
 which yield them, so that they may often
 be distinguished by an experienced palate.
 This is especially the  case with the  po-
 tato  starch and the cassava fecula,  the
 latter of which not unfrequently  has a
 feeble  odour  and a slightly  acrid taste,
 and, according to M. O. Henry, has some-
 times been productive  of unpleasant  re-
 sults when given by injection, probably in
 consequence of a portion  of the poisonous
 principle of the root having been allowed
 to remain in it  from insufficient washing
 in its preparation. (Journ. de Pharm. XX.
 624.)
   Genuine  arrow-root  is  obtained  in  the
 following manner.   The  roots of the Ma-
 ranta, having been  carefully  washed,  are
 beat  into a pulp, which is  thrown into
 water, and agitated  so  as to  separate the
 amylaceous from the fibrous portion.  The
 latter is removed by the hand,  and  the
 water, holding the former in suspension, is
 strained through coarse  linen,  and then
 allowed to stand in  order that the fecula
 may subside. This is washed  with a fresh
 portion of water, and afterwards dried in
 the sun. Arrow-root is brought to us from
 the West Indies.  As kept in the  shops,
 it is in the form of a light, white powder,
 or of small pulverulent  masses, without
 odour or taste.   Chemically considered, it
 is pure starch,  and therefore possesses all
 the  properties  which  characterize  this
 proximate principle of plants. (See Starch.)
 It is  very apt to become musty by long
 keeping and exposure,  and is then unfit
 for use.   We are told that it is occasion-
 ally adulterated with different  kinds of
 meal or flour; but these  may be readily
 detected by their imperfect solubility in
 hot  water.   The  presence of common
 starch,  which  is  said  to be sometimes
 fraudulently added,  is not so easily  ascer-
 tained.  According to Guibourt, the gran-
 ules of arrow-root are  larger than those
 of wheat starch, more shining, and, when
 examined through a microscope,  are en-
tirely transparent, so that the powder in
mass has a less brilliant whiteness.  They
are, on  the  contrary, smaller than  those
of potato starch, from which they also dif-
fer, as asserted by M. Walsh,  in exhibit-
ing, under the microscope, two circular
impressions  instead of one.  (Journ. de
Pharm.  XIX. 432.)  Besides,  arrow-root
imparts less consistence to boiling water
than  either  of these varieties  of starch.
The best method, however, of testing the
purity of this fecula is by the  taste  and
smell.  It  should be entirely free from
odour and unpleasant flavour.
   The cassava fecula, which it may some-
times be important to distinguish, is  apt,
as  before  mentioned, to  have a  feeble
odour, and a taste slightly acrid.  It im-
parts  less  consistence  to  water, in the
same proportion, than either genuine ar-
row-root, or the starch of wheat or the po-
tato.   According to M. Walsh, both this
and arrow-root are sensibly dissolved by
cold water.
   Medical properties and uses.  Arrow-
root  is a light, mild, easily digested,  and,
at the same time, nutritious article of diet,
well adapted to the sick and convalescent,
and much used in all febrile  and inflam-
matory complaints, particularly in those
of  the  bowels and urinary passages, in
which it is peculiarly useful  in  conse-
quence of its demulcent properties.   It is
much employed as food for infants, either
after weaning, or when the mother's milk
is deficient.  The best method of preparing
it is  simply to dissolve it in  boiling-hot
water, with which it. forms a pearly, gela-
tinous solution, or, if in large  proportion,
a jelly-like mass, on cooling.   It should
first  be  made  into a paste with a little
cold water, to which the hot water should
be  gradually added, with brisk agitation.
The  proper  proportion  is  about a table-
spoonful of the fecula to a pint of water.
The  preparation may be rendered more
palatable by lemon-juice and  sugar,  and
wine and spices may be added in cases
requiring or admitting the use of stimu-
lants.  For  infants, it  is  often prepared
with  hot milk or  a mixture of milk and
water, instead  of water alone.
                      Geo. B. Wood.
  ARSENIC.   Black  Arsenic, Arseni-
cum,  Arsenikon, was  first  mentioned un-
der this name by Dioscorides, and others,
about the Christian era.  Aristotle, un-
der the term sandarach, and Theophras-
tus that of arrenikon, referred to a min-
eral of a reddish colour, composed of ar-
senic  and sulphur,  used by the ancients in
painting and  medicine.
  The white oxide of arsenic is mentioned
by Avicenna, in the eleventh  century;
but metallic  arsenic is not distinctly al- 
268
ARSENIC. (Chem. and Pharm.)
luded to until 1649, when Schroeder de-
scribed a  process for obtaining it  It is,
however, to Brandt that we are indebted
for  the earliest accurate account both of
arsenic  and its white oxide.   Since his
time (1733), arsenic has been, under that
name, considered as a distinct metal.
  § 1. Chemical and Pharmaceutical His-
tory.  It  is found  native,  or  in  alliance
with copper, lead, silver, antimony, cobalt,
tin, &c, in Saxony,  Bohemia, Hungary,
Siberia, Norway,  England, &c.  It is also
detected  in the  state of an oxide,  a sul-
phuret and an arseniate. Sometimes it is
volatilized from  volcanoes, commingled
with other volcanic products.
  Arsenic has a brilliant  steel-gray co-
lour,  easily tarnished by exposure to the
air, a circumstance probably dependent on
some slight adulteration, since both Ber-
zelius and Buchner observed that some
specimens remained perfectly lustrous in
open  vessels for a  very prolonged period
of" time. Its texture is generally granular,
occasionally scaly,  and  so  loose as to be
readily reduced to powder.   It is, indeed,
the most friable of the metals.  It is vola-
tile, combustible,  insipid, and inodorous.
Thrown upon burning coals, it gives off a
whitish vapour, and an alliaceous odour.
A plate of copper exposed to  its fumes is
covered with a white coat.
  Its specific gravity varies so much, in
accordance with the means  by which it is
obtained, as to have led to great difference
in the amount, stated by different authors.
Brandt  set it down at 8.308, Bergman
8.31,  Berzelius 5.70, Turner 5.8843, and
Guibourt 5.959.   As Dumas  states it at
between 5.75 and 5.76,  a  weight nearly
the same as that given by Berzelius, that
is to be presumed to be the most accurate.
Our own experiments fix the specific gra-
vity  of arsenic  at 5.767.  (Journ. Col.
Pharm. IV.  108.)
  Arsenic has so  strong an  affinity  for
oxygen, that it is  tarnished by exposure
to the air, or when immersed in water or
alcohol.   Insoluble in those liquids, it is
so  changed by oxygenation, when  boiled
in either,  as to acquire solubility, and thus
by  degrees communicates to them poison-
ous qualities.  According to Hahnemann,
a thousand grains of water in active ebul-
lition over the metal, take up a  grain of
the oxide  in the course of half  an hour.
  Although the great volatility of arsenic
is admitted by all, authors have entertain-
ed  different opinions respecting the de-
gree of heat necessary to  its conversion
into vapour.  Bergman stated it  at 365°,
Klaproth 540°, Thenard and Berzelius
324°, and Christison  and Turner 356°.
Dumas  remarks that in closed vessels it
is volatilized at nascent red heat while,
in the air, its  sublimation  is sensible at
324°. We found the temperature at which
its vapour is given off in open glass tubes,
to be a red heat distinctly visible in the
dark. (Amer. Journ. of Med. Sc. for May,
1832.)  When slowly sublimed, arsenic is
sometimes  found crystallized in octae-
drons, and sometimes  in tetraedrons, the
latter being esteemed the integrant mole-
cule.
  It has been  said, and Thenard sanc-
tions the opinion, that arsenic may, under
pressure, be  fused and cast into moulds.
Berzelius doubts the truth of this state-
ment,  so that as yet we may consider the
question of fusibility unsettled.
  All  authors  of modern date concur in
ascribing the peculiar odour of sublimed
arsenic to  the vapour  of the pure metal,
while  those of an older period refer it to
the  white oxide.  In the  essay already
cited, we have given reasons for believing
it to depend on neither, but to be  the ef-
fect of volatilized  suboxide;  since the
white oxide is entirely destitute of smell,
and metallic arsenic is not volatile at or
near to, the temperature at which the
odour  is  appreciable, a temperature at
which the suboxide is usually vaporized.
  Arsenic,  in  consequence of its insolu-
bility, is not itself poisonous; but as it is
readily converted, in the  stomach, into
soluble and poisonous compounds, its ad-
ministration  in large  doses will  always
prove hazardous.
  The equivalent of arsenic, deduced ex-
perimentally by Berzelius from the com-
position of arsenious and arsenic acids, is
37.7—a number adopted by Dr. Turner
in his latest work.  Thomson, and most
other authors, assume 38 as its equivalent.
  The  black arsenic of commerce is ob-
tained from  the white oxide, or arsenical
pyrites of good quality.  The distillation
is conducted  in  earthen  retorts coated
with a mixture of clay, iron filings, blood,
hair, and  alum.  The  receiver,  formed
also of earthen-ware, is pierced with some
holes to prevent an explosion. An adopter,
formed of sheet iron  rolled up so  as to
make  a tube,  enters  into, and connects
the  necks of the retort and receiver. The
retort is made two-thirds full of the ar-
senical compound, mixed with charcoal,
iron filings,  and lime.   After luting the
retort it is placed in the fire of a galley-
furnace, the receiver being on the out-
side, and heat  is  kept  up moderately for
eight  hours; after which  the whole  is 
ARSENIC. (Chem. and Pharm.)                    269
Buffered to cool.   The iron adopter, when
removed and unrolled, displays the metal-
lic arsenic  in brilliant crystals.  In the
neck of the receiver is found a mixture
of black and white arsenic, while an im-
pure black  arsenical  powder  is collected
from the receiver itself.
   On  a smaller scale,  metallic arsenic
may be procured by sublimation in a cru-
cible, to which another one, in an inverted
position, is adapted by luting;  or, on a still
smaller scale, in a glass tube, sealed at
one  end, and heated by an oil or  spirit-
lamp.   When the  white oxide  is  used,
charcoal will suffice for the reduction; but
when  the sulphuret  is applied to,  lime,
potash, or iron  filings, are necessary to
detain the sulphur.  In the glass tube, the
arsenic collects  just beyond the verge of
red heat, in a shining ring, not much in-
ferior to mercury in colour and brilliancy.
   When  arsenic is exposed, even  for a
short time,  to the air,  it loses its lustre,
grows blacker and blacker, and often, in
process of time, falls to powder.   This
substance, called Fly-stone (fliegenstein,
Germ.; poudre a mouches, Fr.), was long
esteemed a  mixture  of metallic arsenic
and its white oxide.   It is certainly true,
that when  fly-stone  is put  into a  glass
tube, and heated, it is separated into white
oxide  and the metal; but Berzelius, to
whom we are indebted for the examina-
tion of this substance,  considers it a sub-
oxide, consisting of unknown proportions
of arsenic and oxygen.  The limit of ab-
sorption  of  oxygen by cold powdered ar-
senic,  seems to be eight per cent, so that
100 parts of metal take 8 of oxygen.  If
this be a definite compound, it must con-
sist of 8 atoms of arsenic and 3 of oxygen.
   Arsenious Acid, Arsenic of commerce,
White Arsenic,  White Oxide of Arsenic,
RaCs-bane, is the best known and most
common of the preparations  of arsenic.
Once  called white oxide of arsenic, be-
cause  its acid properties were unknown,
it is now, both by composition  and charac-
ter,  placed by  the  side  of phosphorous
and  hyponitrous acids.  It is  volatile at
425° F.  (Journ. Col. Pharm.  Vol.  IV.),
and when recently sublimed, presents oc-
taedral crystals  of adamantine lustre, or
an amorphous vitreous mass equally trans-
parent  According to Wohler, it is  di-
morphous, assuming,  under unknown cir-
cumstances,  the form of six-sided  scales
derived from a rhombic prism.  Exposed
to time and air,  it loses its  transparency,
becomes opaque, less  hard, and 'decreases
slightly in density.   The  specific gravity
of the vitreous  acid  is 3.699 (Wollas-
                 23*
ton), 3.7386 (Guibourt) ;  that  of the
opaque variety, 3.729 (Harepath), 3.695
(Guibourt).   Dr. Turner states the spe-
cific gravity of vitreous arsenious  acid to
be 3.7.   According to our own observa-
tions, the compact opaque variety is 3.656,
the vitreous from 3.208 to 3.333. It is not
easy to conjecture the cause of the conver-
sion of vitreous into  opaque arsenic, but
moisture seems essential to the change.
  It has been generally asserted that the
white variety is more soluble in water than
the other, and Guibourt's authority goes
to show, that while 0.96 parts of the glass
are soluble in 100 parts of cold  water, the
same quantity of water will dissolve 1.25
parts of the  opaque variety.  According
to the same authority, 100 parts of boiling
water dissolve 9.68  of the first, and 11.47
of the other;  and when the  temperature
falls to 59° F. the solution of vitreous ar-
senic retains 1.78, and that of the  opaque
variety 2.9.  If these experiments can be
perfectly trusted, it is probable that, as in
the case of phosphoric and pyrophosphoric
acid, these two compounds of oxygen and
arsenic  are isomeric, agreeing in  compo-
sition and equivalents, but modified by in-
ternal atomic relations.  We  made, on
this subject,  experiments (Journ.  Frank-
lin Inst.  Loc. Cit.)  which  throw some
doubts on the correctness of Guibourt's
observations.  We found that the vitreous
arsenic required longer boiling than the
white variety, but  that finally, solutions
of both were obtained, agreeing in specific
gravity.   We  also found the arsenious
acid more soluble in boiling water, than
has been stated by any  authority what-
ever.  In our hands, one thousand parts
of water, at 60° F., dissolved from 12 to
16  parts  of  the white arsenic; and the
same quantity of boiling water, when fully
saturated,  held in solution 148 parts, and
retained, on  cooling,  from 25 to 40 parts.
The  very singular  effect of  prolonged
time, both on the quantity dissolved, and
that retained after refrigeration, is  worthy
of particular attention.
  The  point of fusion  is a little  higher
than that of sublimation, so that it  can be
melted only under pressure, or when the
temperature  is so suddenly  raised as to
melt the mass, before  the  whole is  va-
porized.
  The taste  of arsenious acid  is said by
Bergman to be acid, subdulcid; Hahne-
mann, Dr. James Gordon, and Walker,
think it  sweet; Addington  and  Chris-
tison esteem  it insipid;  Zacchius, Or-
fila, Berzelius, Fodere, &c,  declare it
to be sharp and acrid; while Dr. Turner 
270                     ARSENIC.  (Chem. and Pharm.)
is satisfied, from personal observation, that
it may be deliberately tasted without ex-
citing more  than a very faint impression
of  sweetness  and  perhaps  of  acidity.
These discrepancies  arise probably from
the variety  in the modes  of observation.
We think that the taste of  a strong  hot
solution is rough, as stated by Navier ;
while  that of the powder,  or a weak cold
solution, is so feeble as to be indescribable,
and  scarcely to be perceived by common
palates.  When most distinct, it is very
nearly the same with that of a solution
of sulphate of zinc.
  White arsenic, in  a pulverulent form,
is obtained as a secondary product in the
chambers, or prolonged chimneys, attach-
ed to furnaces  used for roasting or smelt-
ing various  ores,  especially  those of co-
balt lead, and tin.  Arsenical pyrites  are
also roasted  expressly to obtain  this pro-
duct.  It is afterwards purified and con-
solidated by sublimation in large iron mat-
trasses. In the laboratory, it may be made
by heating the metal in open vessels, or
by digesting  it in dilute nitric acid.
  The arsenious acid of commerce is in
vitreous masses, of which  the interior is
almost perfectly transparent,  while   the
exterior presents  a white or milky  ap-
pearance.
  Besides water, alcohol, oils, and acids,
dissolve white arsenic;  but in  general,
organic products lessen greatly the power
of any liquid solvent; so that even when
white arsenic is adherent  to the coats of
the stomach, or is found commingled with
the contents of that organ, it may not be
detected in the liquid obtained by filtra-
tion.
  Solid arsenious acid is readily detected
by the alliaceous odour  and  white fumes,
mixed with umber-looking vapour, which
arise, when it is thrown  on red-hot char-
coal.  When the quantity  is too small to
admit of such an experiment it may be
mixed with powdered charcoal, placed in
the bottom of a glass tube sealed at  one
end, and cautiously heated  to redness over
a small spirit-lamp.   The production  of a
brilliant steel-gray ring  indicates the pre-
sence of metallic arsenic.   By cautiously
chasing the arsenic by heat, from one part
of the tube  to another,  it is  convertible
into octaedral crystals of arsenious acid,
whose adamantine lustre  is farther  evi-
dence of the presence of arsenic.  One or
two of these, thrown on burning coals,
will, by the peculiar odour  of garlic or
phosphuretted hydrogen, complete the evi-
dence of the detection of arsenic. A very
critical observer may choose to dissolve  a
part of both the metal and oxide, and re-
sort, for full assurance, to the liquid tests.
  In simple aqueous solutions, the detec-
tion of arsenious acid is remarkably easy.
  1st.   Ammoniated  sulphate  of copper
throws  down  an  apple-green flocculent
precipitate of arsenite of copper.
  2d. Ammoniated nitrate of silver causes
a canary-yellow arsenite of silver to  fall.
  3d. Lime-water throws down white in-
soluble  arsenite of lime.
  4th.  By means  of sulphuretted hydro-
gen, or  its aqueous solution, a yellow ses-
qui-sulphuret of arsenic (orpiment) is form-
ed.  To  develope this precipitate fully, the
solution should be  heated, or there should
be  added a drop  or two of hydrochloric
acid.  In any case, the precipitate is very
suddenly produced. This reagent will de-
tect arsenic in a  solution containing the
TffTi'sinr  of its  weight of the poison.
  5th.  The soluble hydrosulphates do not
disturb  the solutions  of arsenious acid,
until a  drop  or two of a strong acid is
added, when there suddenly appears a yel-
low precipitate of sesqui-sulphuret of ar-
senic.
  6th.  By means  of black flux  and the
heat of a spirit-lamp, any of the foregoing
substances may be made to produce,  in a
glass tube, a bright metallic  crust whose
characters may be farther examined by
ignited  charcoal, oxidizement, &c. &c.
  By the combustion, in pure oxygen, of
a known weight of regulus of arsenic, and
the measurement  of the  quantity of the
gas absorbed in the process, Thenard de-
termined  the   composition of  arsenious
acid; which consists of
  2  atoms of arsenic = 940.77  or 75.82
  3  atoms of ox.     = 300.00  or 24.18

  1  atom of ars's acid   1240.77 or 100.
  Berzelius  analytically  confirms The-
nard's  synthesis; so that we may consi-
der arsenious acid as composed of, in round
numbers,  3 X 8 ox. and 2 X 38 arsenic; or

2As+30, or As.

  Arsenic Acid  is of a  milk-white co-
lour, has a 60ur metallic taste,  reddens
vegetable blues, and combines with alka-
lies, so as to form  salts termed arseniates.
It is much more soluble in water than ar-
senious acid, being dissolved  by five or six
times  its weight  of  cold, and  a much
smaller proportion of hot water.   It is re-
marked by Berzelius that it partakes of
the property of phosphoric acid, inasmuch
as  it resMs, even in fine powder, imme-
diate solution, but is, by agitation, finally
completely taken up. 
ARSENIC. (Chem. and Pharm.)
271
   When entirely anhydrous, arsenic acid
attracts  atmospheric moisture, and is  re-
duced in density to 1.935.  To its greater
solubility,  probably may be ascribed  its
superior poisonous  quality.   It is totally
deprived of water at a temperature below
red  heat,  and has a  specific  gravity of
3.39.  At  red  heat  it is  partially de-
composed, presenting then a melted mass
composed of"  both the acids of arsenic.  At
a higher heat it gives off oxygen,  and is
transformed  into  arsenious acid, which is
volatilized.
   Its composition, on the authority of Ber-
zelius, is, of oxygen, 5 atoms, or 34.72;
arsenic, 2 atoms, or 65.28; = 100.00.
   Mitscherlich has  shown that phos-
phoric and arsenic acids have the same
relation  to each  other as the sulphuric
and selenic.  Saturated by the same bases,
they furnish salts of the same crystalline
form, or they are isomorphous; and, as is
remarked by  Berzelius, it was this very
example of such relation which  led the
great crystallographer to the doctrine  of
isomorphism, now esteemed so important
to the science.
   Arsenic  acid is made by boiling eight
parts of arsenious acid with two  parts of
strong hydrochloric acid, with the gradual
addition of twenty-four parts of nitric acid
of the specific gravity 1.25.   The  mix-
ture,  after distillation in glass to the con-
sistency of a syrup, should be transferred
to a platinum capsule, and exposed to a
heat  below  redness  for a  considerable
time.  The complete expulsion of water,
and  redundant nitric  acid,  leaves  anhy-
drous arsenic acid.
   Chemically, this  substance may be de-
tected in the solid state by its alliaceous
odour  when  heated on  charcoal, by  its
taste, its solubility, and by its reduction
by heat and  charcoal in a glass  tube, in
which the  arsenical crust will be formed.
   From  simple  aqueous solutions,  it is
precipitated,
   1st  by acetate of copper, of a blueish
white (arseniate of copper);
  2d. by nitrate of silver not acid, brick
red (arseniate of silver);
  3d. by sulphuretted hydrogen, a yellow
sulphuret is precipitated, whose composi-
tion  is like that  of the  acid,  containing,
according to  Berzelius, 2 atoms of metal
and 5 of sulphur, or As'Ss6.
  If farther  evidence  be desirable, the
precipitates may be submitted to reduc-
tive processes, and the crust tested in the
various modes by which the presence  of
metallic  arsenic is manifested.
   Two Hydrurets of arsenic are known
at present  One, a solid, consists of one
equivalent of each constituent; the other,
a gas, is composed of two atoms of arsenic
and three of hydrogen condensed into two
volumes.
   The Protohydruret was first noticed by
Ritter.  Davy formed it by galvanic re-
action on water,  when a piece of arsenic
was attached to the  negative pole.   Sou-
beiran, on the contrary, could produce it
only by submitting an alloy of arsenic and
potassium to the action of water.
   It is  a  chestnut or chocolate-coloured
solid, insoluble in water, and  capable  of
bearing, unaltered,  in nitrogen  gas, a
cherry-red heat.   Heated  in  oxygen, it
catches fire, and  produces water and ar-
senious  acid.
  Its composition, carefully explored  by
Soubeiran (Annal. de Ch. et Ph. XLIII.
422.), is one equivalent of arsenic and one
of hydrogen.
  The  Sesquihydruret, arsenuretted hy-
drogen, Arseniure Trihydrique of Ber-
zelius,  was discovered by Scheele, no-
ticed by Proust, and  elaborately examined
by Tromsdorf, Stromeyer, Dumas, and
Soubeiran.   The latter prepared  it per-
fectly pure, by the action of concentrated
hydrochloric  acid on an alloy  of equal
parts of arsenic and  zinc.   The resulting
gas, being entirely absorbable by a satu-
rated solution of sulphate of zinc, showed
thus its exemption from the presence of
free hydrogen, found in all the specimens
prepared in any  other manner.  Dumas
found that the purest gas  he could pro-
duce  was intermingled with  more  than
twice its bulk of free hydrogen.
   Arsenuretted hydrogen is permanent at
all common temperatures, but at — 40 c
is  condensed into a  limpid liquid resem-
bling ether.  According to Dumas, its spe-
cific gravity is 2.695.  It is highly offen-
sive to  the  smell, and, mixed with air,
even  in the  proportion of one tenth  part
rapidly destroys  animal life.   In smaller
proportion, it produces anxiety, lassitude,
vertigo, nausea,  vomiting,  and excessive
constipation.  To the inhalation of this
gas, prepared by heating arsenic in an al-
kaline lixivium,  science owes the loss of
M. Gehlen.  Stromeyer and Berzelius
thought it insoluble in water, but Soubei-
ran has shown that water absorbs about
one-fifth of its bulk,  and that the solution
causes precipitates in metallic solutions.
  Heated  in a glass  tube, one volume of
the gas, after depositing its arsenic, yields
one and a half volumes of hydrogen gas.
Two volumes, by complete combustion in
three volumes  of oxygen,  produce one 
272
ARSENIC. (Chem. and Pharm.)
atom  of arsenious acid and three atoms
of water.   Arsenuretted hydrogen, by in-
ference from these facts, is composed of
two atoms of arsenic and three of hydro-
gen, and two volumes are  formed by one
of arsenical vapour and three of hydrogen.
Soubeiran confirmed this  view, by the
reaction of arsenuretted hydrogen on the
salts of copper and silver.
   In solution, the arsenuretted hydrogen
is  not likely to be used  as  a poison.   Its
detection  is, however, easy, as  its precipi-
tates  are  of a brownish-black  colour in
most  of the  metallic  solutions,  while  it
produces no change in alkaline  and earthy
salts.
   Even the y^."^ part of the gas may be
detected in a gaseous mixture, by means
of a solution of perchloride of mercury.
When exposed to arsenuretted hydrogen,
a solution of corrosive sublimate is soon
covered with a pellicle of arsenious acid
and calomel,  followed by a metallic  coat-
ing of amalgam of arsenic, which becomes
gradually more and more manifest When
unmixed  arsenuretted hydrogen has been
thus treated,  there remain pure hydrogen
and a solution of arsenious  acid.
   Fluoride of Arsenic is composed, ac-
cording to Dumas, of one atom of arsenic
and three of fluorine, and has, according
to Unverdorben, a  specific  gravity of
2.73.    It  is liquid,  volatile,  colourless,
heavier than water,  and very poisonous.
The least drop causes a painful sensation
of burning,  excites  thick  blisters  filled
with  pus, and finally creates  ulcers ex-
ceedingly difficult to  heal.
   It is easy to detect this substance by the
reaction of water, in  which may be found
arsenious  and hydrofluoric acids.
   It is obtained by the distillation of fluor
spar, arsenious and sulphuric acids.
   The Chlorides of Arsenic may, accord-
ing to Berzelius, be formed by distilling
arsenic with calomel and corrosive subli-
mate,  forming protochloride and trichlo-
ride respectively.  Dumas appears to think
that all the  suggested processes produce
one substance, trichloride, a fuming, vola-
tile, colourless, and very poisonous liquid,
heavier than water,  and transformed by
water into arsenious and muriatic acids.
As the best method,  he suggests the in-
troduction into a tubulated  retort, of ar-
senious acid  with ten times  its weight of
sulphuric acid, and, at 212° F.,  the farther
introduction of fragments of common salt
The  pure chloride  may be collected  in
cooled receivers.
   Dr. Davy  esteems as a sesquichloride,
the product of the combustion of arsenic
in chlorine gas.
  The chlorides are easily tested by water,
and  the detection of the  arsenious and
muriatic acids formed by it.
  Bromide, Iodide, and Seleniuret of ar-
senic are producible by the direct union
of their  constituents.  The bromide is a
colourless liquid, yielding,  by water, ar-
senious and hydrobromic acids.  The iodide
is a  red crystalline solid, resolved in the
same way into arsenious and hydriodic
acids.
  The sulphurets of arsenic are, accord-
ing to Berzelius, not less than five; but
as most writers describe  only three, and
as these alone are accessible to the public,
they merit exclusive attention.
  Realgar, red, or protosulphuret of ar-
senic is  found  in the mineral kingdom,
and is also formed by fusing together one
part of sulphur and two of arsenious acid.
The mass is semicrystalline* and of a red
colour.   According to Dumas and Berze-
lius, it consists of one equivalent of each
of its constituents.
  Orpiment, yellow,  or  sesquisulphuret
of arsenic  is also found as a mineral.  It
may be artificially produced by treating a
solution of arsenious acid by sulphuretted
hydrogen, or by distilling  together mix-
tures of arsenic or  arsenious acid with
proper proportions of sulphur.
  It corresponds in  composition with ar-
senious acid, being formed of two atoms
of arsenic and  three of sulphur.
  Persulphuret of Arsenic is of a citron-
yellow colour, and is obtained by precipi-
tation  by sulphuretted hydrogen, from a
solution  of  arsenic  acid;  or,  better, by
adding  an excess of  muriatic acid  to a
mixture  of the solutions of  an alkaline
arseniate, and  a sulphuret of potassium
or sodium.
  Its elements  consist of two atoms of ar-
senic and five of sulphur.
  All  these sulphurets are insoluble in
water or alcohol, but  soluble in alkaline
solutions and those of alkaline sulphurets.
They displace sulphuretted hydrogen from
sulphuretted hydrosulphates, and carbonic
acid from carbonates and bicarbonates,
forming, in consequence of complicated
changes, sulphuret of arsenic  with  bases
of alkaline sulphurets. Cold water slowly,
and  hot water rapidly,  decompose  the
sulphurets, sulphuretted hydrogen and ar-
senious acid being the result.
  They  are used in dyeing and painting,
and  may therefore  occasion  fatal  acci-
dents.   Although not very  poisonous, be- 
 cause of their insolubility, Orfila  has
 shown that they  are deleterious  when
 taken internally.
   They may be readily detected by  the
 characters already given, and by  reduc-
 tion.
   The reduction may be effected by mix-
 ture with soda, potash, or black flux, and
 the  application of a spirit-lamp to the glass
 tube which is made to contain them.
   We are  as yet unacquainted with any
 compounds  of arsenic with azote, carbon,
 boron, or silicon.
   Arsenic  combines  readily with  phos-
 phorus, when equal parts  of the constitu-
 ents are distilled together over a moderate
 fire.   Phosphuret of arsenic is  of a bril-
 liant black colour, unaltered by water» in
 which it is therefore convenient to pre-
 serve it (Annal. de Chimie.  XIII. 139.)
   Two impure sulphurets, of a highly poi-
 sonous quality, are  sold in the  shops, un-
 der the names of orpiment  and king's yel-
 low.   The former is  an admixture  of or-
 piment and arsenious acid, and the latter,
 according to Christison,  a compound of
 sulphuret of arsenic, caustic lime, and free
 sulphur.   Guibourt  has shown that the
 former sometimes holds as much as 96 per
 cent, of the oxide.
   King's yellow in  solution in water, is
 not affected by lime-water  or sulphuretted
 hydrogen.  Ammoniacal nitrate of silver
 causes a dirty brown, and ammoniacal sul-
 phate  of copper a scanty dirty lemon-yel-
 low  precipitate.   Its sulphuret may  be
 separated by ammonia, and  subsequently
 thrown down by an acid.   Diluted hydro-
 chloric or acetic acid will  separate the
 lime from the free sulphur, and yield it
 up to oxalate of ammonia or the alkaline
 carbonates.   The free sulphur may then
 be known by its fusion, combustion, and
 sulphurous acid-vapour.
   Arsenical  Alloys are  easily formed,
 and are generally very brittle and fusible.
 Many of them decompose water, and pro-
 duce the  acids and the hydrurets  of  ar-
 senic.  They are consequently unsafe and
 unstable compounds, liable to reaction with
 atmospheric moisture, and  to evolution of
a poisonous gas when handled.  The alloy
 of arsenic and tin affords the best means
 of obtaining trihydniret of arsenic.  They
 may be formed by direct union, as exem-
 plified by tin platinum and potassium;  by
reaction of the bases  of the earths and al-
kalies  on arsenuretted hydrogen,  or  by
treating metallic salts by arsenuretted hy-
drogen.
  The Salts of Arsenic, likely to engage
the attention of the physician, or medical
ARSENIC. (Chem. and Pharm.)                    273
                 jurist  are  the  arsenite and arseniate of
                 the alkalies, particularly those of potash;
                 the pigments of arsenite of silver and ar-
                 senite  of copper; and  the  sulpharseniate
                 of the  sulpho-base of lime, resorted to as
                 a depilatory.
                   The arsenites,  notwithstanding their
                 importance, have not been examined with
                 much  care.  Those  of the alkalies  are
                 very soluble  in water, make green  the
                 vegetable blues, and are not crystallizable.
                 The arsenites of copper and silver are in-
                 soluble in water, but soluble in an excess
                 of arsenious acid, and  in almost any acid
                 which  does not form with their bases  in-
                 soluble compounds.
                   Treated  with charcoal  or black flux,
                 the arsenites yield metallic arsenic, which
                 is either sublimed or retained in the form
                 of an alloy.
                   The  insoluble  arsenites yield soluble
                 salts by being  boiled with carbonate of
                 potash  or soda, in which the poison may
                 be detected by the usual tests.
                   The  soluble  arsenites are,  if neutral,
                 distinguished by giving a yellow precipi-
                 tate with nitrate of silver; a green, with
                 sulphate of copper;  and  a white, with
                 lime-water. When acidulated with acetic
                 or muriatic acid, sulphuretted hydrogen
                 throws down orpiment.
                   The arseniates, though not so frequently
                 used, have been more thoroughly exam-
                 ined.   These salts resemble  in  composi-
                 tion those  of  phosphoric acid, with which
                 they are frequently isomorphous.   They
                 usually bear a red heat without decompo-
                 sition,  but, when charcoal is present sub-
                 mit to  decomposition, with the evolution
                 of metallic arsenic.
                   In conducting this experiment on the
                 alkaline arseniates,  a strong heat is ne-
                 cessary ; but  the heat  of a spirhvlamp is
                 quite adequate  to  the subversion  of the
                 arseniates  of  lead, copper, or silver. The
                 insoluble arseniates may be  converted into
                 soluble salts,  by being boiled  in a  strong
                 solution of the alkaline carbonates; in
                 which state, if perfectly neutral, they may
                 be tested by nitrate of silver, which will
                 afford a brick-red precipitate; by nitrate
                 of lead, which will throw down white  ar-
                 seniate of lead; and  by sulphate  of cop-
                 per, which developes a green precipitate.
                 After removing, by filtration, the cupreous
                 precipitate, the liquid,  much reduced by
                 evaporation, gives, by alcohol, according
                 to Chenevix,  a  blue precipitate.  Berze-
                 lius esteems  the first  a subsalt, and the
                 latter a neutral  one.
                   In closing the chemical part of this  ar-
                 ticle, we  may observe that it  has been 
274
ARSENIC. (Toxicol.)
purposely freed from complication with
the medico-legal inquiries.   The validity
of the various tests, their modification by
complex organic mixtures, and the many
nice precautions essential to perfect  suc-
cess in the search after arsenic, will be
placed in a much stronger light, by being
treated of in a separate place.  The want
of such an  arrangement is felt by every
one who comes to  the  subject, without a
great deal of antecedent preparation.
  The table which closes this section is
compiled from Dr. Turner's last (5th) edi-
tion  of his work on chemistry.
        Arsenic.
Arsenious Acid


Arsenic Acid

Protochloride
Sesquichloride
Periodide
Sesquibromide
Protohydruret
Arsen. Hydrogen
Protosulphuret
Sesquisulphuret
Persulphuret
75.4.  2 eq. + Oxygen   24.
        Equiv.      Formulae.
3eq.=  99.4 2As + 30. or As.
75.4.

37.7.
75.4.
75.4.
75.4.
37.7.
75.4.
37.7.
75.4.
75.4.
2 eq. + Oxygen   40.    5 eq.

1 eq.-f Chlorine   35.42. 1 eq.
2 eq.-j-Chlorine  106.26. 3 eq.
2 eq. -f- Iodine    631.5.  5
2 eq. -f Bromine  2355.
1 eq.-|-Hydrogen  1.
2 eq. -j- Hydrogen  3.
1 eq.-f Sulphur   16.1
2 eq.-f Sulphur   48.3
2 eq.-f Sulphur   80.5.
 eq.:
3 eq.:
1 eq.:
3eq.:
1 eq.
3 eq.
5 eq.
: 115.4

:  73.12
: 181.66
: 706.9
: 313.6
:  38.7
:  78.4
:  53.8
= 123.7
: 155.9
2As -f 50. or As.

As -f CI. or AsCl.
2As-f 3C1. or As^CR
2As-f5I.  or As*ls.
2As -f 3Br. or As^JM
As + H. or AsH.
2As + 3H. or AsW.
As4-S. or AsS.
2As4-3S. or As*S».
2As4-5S. orAs2S*.
TriarseniateofSoda 93.9.   3 eq.-f-115.4.

Triarsen. of Potash 141.45.  3 eq.-(-115.4.

Diarseniate of do.   94.3.   2 eq.-f 115.4.

Arseniate of do.     47.15.  1 eq.-f 115.4.

Triarsen. of Silver  348.    3 eq. 4-115.4.
1 eq.=209.3  3Na4-As.

1 eq.=256.85 3K4-As.

leq. = 209.7  2K-f As'.

leq.= 162.55 K + As.

1 eq.=463.4  3Ag-f As.
  § 2.  Toxicological Effects, and Modes
of Detection.  In  medico-legal investiga-
tions into cases of poisoning by arsenic,
the chemist is commonly embarrassed by,
1st. the  organic matter  with which  the
poison  is commingled, and 2d. the very
minute quantity preserved in the stomach
and bowels  after hours of copious vomit-
ing and  purging.   The former often  ob-
scures by discoloration,  the  precipitates
produced by the  liquid reagents; or by
viscosity, or  chemical action,  prevents
their descent and aggregation. The latter
often demands  an exquisite skill in mani-
pulation, because a slight loss, or a minute
error of  process, may prove irremediable.
   If possible, in suspected cases, the whole
primoz via  should be obtained, and care-
fully closed by ligatures at the ends, so as
to retain their contents.  Before opening
them,  their external appearance  should
be carefully and minutely noted, and parts
apparently most affected, separated from
the rest by double  ligatures,  antecedent
to the insertion of the knife or scissors.
By the  same means, the contents of the
stomach, of the duodenum, of the other
small intestines, and also of the colon and
rectum, should be disparted.
  The examination of the interior should
commence with the cesophagus, and should
have reference to the morbid appearances,
and  the detection of  minute,  but solid
pieces of the poison.  The former will be
treated of in a separate place;  the latter
are to be sought for  first  by the eye, as-
sisted, if necessary, by such a  lens as is
used  by watchmakers.  Afterwards, the
ends of the fingers should  be carefully ap-
plied to every  part  of the  surface, and
with   most  particularity  to those spots
which exhibit marks of inflammation  or
disorganization.  Solid particles thus found,
should be collected together, and washed
in a  clean watch-glass  with a  few drops
of cold water,  and immediately removed
and dried.   The liquid used in cleansing
them  should  be  carefully preserved for
the  application  of dissolved tests.  The
solid,  placed at  the  bottom of a dry-test
tube,  and covered  with  fresh and  dry
black-flux, and subjected to the action  of
a small spirit-lamp flame, will afford, when
it consists of arsenic,  the metallic ring. 
ARSENIC. (Toxicol.)                         275
That may be subsequently tested by its
odour, when thrown on incandescent char-
coal, and by the various precipitates, which
a solution  of its  oxide may be made to
present.
  The other subdivisions  of the prima
via  should be explored  in the same pa-
tient and careful manner, and, if possible,
a still more minute examination should be
made of  the  stomach and  its contents.
The detection there  of solid particles is
not  unusual, and when made, saves an
immense amount of subsequent labour and
anxiety.
  In the  pursuit of this preliminary ex-
amination, the contents of  each  section
of intestine should be placed in a proper
separate  repository,  together with  the
washings  of that part, made for a better
view of the internal surface.  The vessel
thus used, should be immediately marked
and  set aside.
  Failing  the detection of solid  arsenic,
a solution of the contents of the stomach,
if already  formed,  should  be examined;
or,  if not formed, prepared  for examina-
tion, in the following manner.   If there
be found in the stomach a sufficiently thin
fluid, it should be filtered;  or if too thick
for that process,  it should  be diluted with
distilled water, and boiled for at least half
an hour, and then filtered.    But very fre-
quently the stomach is found nearly empty,
and coated within with a viscid substance,
which is often so adhesive  as to cause the
removal of the  mucous lining in the at-
tempt to  scrape  it off.   When a quantity
of such matter can be separated, with or
without the inner coat of  the stomach, it
should  be well  boiled in  distilled water,
and filtered, taking care in this,  as in all
cases, to preserve the filter and its  solid
contents  for farther  examination, if that
should be found necessary.
   When  the stomach is entirely empty,
or when its contents fail to yield  proofs of
the  existence of the poison sought for, it
should be cut  into pieces, and boiled  in
distilled water.  Some writers, and among
the  rest, Berzelius, recommend  the addi-
tion of a little caustic potash to the water,
by  which means the solution is  more ef-
fectual, and the filtration easier.  After
filtration, various processes have been sug-
gested for the removal of the animal mat-
ter, and the precipitation  of the arsenic.
   Berzelius recommends the following
method.   Supersaturate the liquid  with
hydrochloric acid, filter,  and transmit  a
stream  of sulphuretted hydrogen gas.  If
there is arsenic present,  a yellow colour
is  soon observable, and if abundant, the
newly-formed   sulphuret  of  arsenic  is
thrown down.   If not copious, there is no
precipitation until,  by heat, the liquid is
concentrated.   Although the presence of
arsenic will cause these phenomena, the
operator is not  certainly to infer its exist-
ence from such appearances  alone, since
they may  be produced by other  causes.
The solution  and  precipitate  are to be
transferred to a small filter, and the filter
washed with water  until the  solid matter
has been made as clean as possible.  If
the quantity of it be  too  small to be re-
moved from the  filter  by a penknife, the
sulphuret  should  be washed through it by
liquid  ammonia,  and that driven off by
evaporation from  a thin watch-glass. The
still adhering animal matter is to be de-
stroyed by projecting the result, little by
little, into melted nitre at the bottom of a
glass tube.  The arseniate of potash thus
formed is dissolved in  a few drops, or as
small a quantity as possible of water, to
which an addition of lime-water in excess
is  to be made,  so as to throw down a pre-
cipitate of arseniate of lime.  A boiling
         heat completes the precipitation.
         The arseniate of lime, collected
         on a  filter, dried at  a low red
         heat, and intimately mixed with
          fresh burnt charcoal powder, is
         to be  introduced into the bulb of
         a glass tube of the  shape and
          calibre  expressed in the annex-
          ed figure.
            When the product is large, a
          straight tube sealed at one end
          will  answer the purpose; and
          we see no good reason for pre-
          ferring a tube of the shape re-
          commended by Berzelius, to a
          straight one of small dimensions,
          inflated, if necessary, into a bulb
          at the sealed  end.  After such a
          moderate warming as will dispel
          moisture  from  the matter and
          the tube, the bulb  is to be heat-
          ed until the glass begins to melt.
          OThe  arsenic is thus reduced, and
          is collected  in  a  characteristic
          state in the narrow part of the
          tube.
   Berzelius suggests, for the detection
 of arsenic acid, the use of hydrosulphuret
 of ammonia, instead of sulphuretted hy-
 drogen,  which acts imperfectly  on that
 acid.  After acidulating, as before,  with
 hydrochloric acid, and filtering, surcharge
 with  hydrosulphuret  of ammonia,  heat
 gently for an  hour, precipitate by hydro-
/ 
276                          ARSENIC.  (Toxicol.)
chloric  acid, collect on a filter, and treat
the product as  in  the case of arsenious
acid.
  In Germany, the process  of Valentine
Rose is in current use.   His directions
are, to boil the suspected matter with pot-
ash, filter,  boil a second time, and add, by
degrees, during  ebullition, nitric acid, un-
til the liquid becomes decidedly acid, lim-
pid, and of a bright yellow colour. Filter
while  hot, and  add carbonate of potash,
not to complete  saturation.  Bod to dispel
carbonic acid, and add lime-water until a
precipitate is formed. The lime first satu-
rates the excess of nitric acid, and then
is thrown  down with the arsenic as ar-
senite of lime,  along with animal matter
and  phosphate of lime.   The precipitate
is to be collected on a filter, washed, dried,
and  mixed with  charcoal  and  half its
weight of powdered vitreous boracic acid.
A bright-red heat  causes the boracic  to
supplant the arsenious acid, which is sub-
sequently  decomposed by  the  charcoal.
The arsenic is then found just beyond the
sphere of the red heat usually in a bright
ring.   When  in very  minute quantity,  it
merely darkens the tube, but may be made
to give  a  metallic look  by rubbing the
gray powder on white paper with  some
hard  substance, such  as a  glass  tube.
When the paper is burnt  the arsenical
smell is observable.
  Professor Hare proposes to peroxidize
the arsenic, and to destroy animal matter,
by boiling the suspected substance to dry-
ness, along with strong nitric acid, redis-
solving and forming  by  lime-water, ar-
seniate of  lime, and reducing by charcoal
and heat.  This process has the merit of
great simplicity, and is calculated also to
discover any  possible preparation of ar-
senic.   The learned Professor detected in
this  manner, in a  very complex  organic
mixture, the  arsenic  which did  not re-
spond  to any  liquid reagents.
  Orfila, who  is followed in France, de-
stroys  the animal matter with hot nitric
acid, neutralizes with potash, adds hydro-
chloric  acid in  slight  excess, precipitates
by  a solution of  sulphuretted  hydrogen
and  heat;  filters,  washes  through with
liquid ammonia, and by neutralizing the
ammonia with  hydrochloric  acid, again
throws down  the  sulphuret and  collects
it  Christison  finds great fault with him
for not pursuing the  inquiry farther, but
as he has  in another place, stated the
mode of reducing the  sulphuret  and the
various methods of recognition of  arsenic,
the remarks may be deemed hypercritical.
   In England, and generally in the United
States, the preferred process of reduction
is that suggested  by Professor Robert
Christison,  in  the second edition of his
great work on poisons.   It is that, too, to
which Dr. Turner has lent  his high  au-
thority, and  which on  the whole is best
calculated to detect  the presence, in or-
ganic mixtures, of minute portions of ar-
senious acid.
  " The first step  of the process for  de-
tecting arsenic in organic fluids, is to pro-
cure a transparent solution.  For this end,
it is sufficient to boil the suspected mate-
rial for half an hour, distilled water being
previously added, if necessary, and any
solid matters being cut into  small pieces.
The  coarser  solid particles being then
separated by a gauze filter, the fluid is to
be filtered through paper.  In the case of
the contents  or tissues of the stomach,  the
filtration is slow, occupying at least thirty-
six hours.  If greater dispatch is neces-
sary,  it is useful to boil with  it a little
caustic potash, previous to filtering through
paper.
  " The next step is to free the fluid as
much as  possible from  animal matter, in
order to procure subsequently a sulphuret
which shall  not yield empyreuma when
reduced;  for animal matter in solution is
very apt  to be  thrown  down along with
the sulphuret;  and  a  small quantity of
animal  empyreuma will render the  re-
duction precarious.   The removal of ani-
mal matter may sometimes be sufficiently
accomplished by acetic acid alone, which
coagulates casein," (and albumen).
  "In  order to ascertain whether, after
this addition, the fluid is ready for the sul-
phuretted  hydrogen,  neutralize it with
ammonia  or potash, and test a few drops
with  ammoniacal nitrate  of silver, as a
trial test.   If it gives a characteristic pre-
cipitate, the oxide is pretty abundant  the
fluid is free enough of animal matter, and
the process for converting the arsenic into
sulphuret may be proceeded  with.  If  the
silver test does not act characteristically,
another step will be required for removing
the animal matter.
  " For this purpose, all that is necessary
is to evaporate the solution, at a moderate
heat to dryness, to form a solution anew,
by boiling successive portions of distilled
water on the residue, and to filter this so-
lution," (after it is cooled).
  " The fluid to be subjected to trial, must
be neutral, or acidulated with a vegetable
acid.   If  the fluid is alkaline, the  sulphu-
retted hydrogen will  not act, because  the
precipitate it would otherwise form is  so-
luble  in  the alkalies.   If,  on the other 
ARSENIC. (Toxicol.)                          277
hand, a mineral acid, at least nitric or sul-
phuric acid,  be present in excess, an ex-
cess of sulphur is thrown down, which
would subsequently prevent  the  process
of reduction from succeeding.  Hence, if
the fluid reddens  litmus, and the acid is
either unknown, or a mineral acid, it must
be  neutralized with potash;  if it  is alka-
line,  it must be  acidulated  with acetic
acid; and it is well to acidulate with that
acid in all cases.  Sulphuretted  hydrogen
has no action on diluted acetic acid.  The
fluid being thus prepared, is to be  subject-
ed to  a stream of sulphuretted hydrogen
gas, for ten or fifteen minutes.  The first
portions of gas turn the arsenical  solution
to  a  bright lemon colour, and the subse-
quent portions throw down  a flocculent
precipitate, of a sulphur-yellow tint, which
is the sulphuret  of arsenic,—the  sulphur
of the reagent unites with the metal of
the oxide, and the hydrogen of the former
unites with  the oxygen of the latter, to
produce water.  If the proportion  of oxide
in  solution is small, no  precipitate, but
only a yellowness or yellow milkiness is
caused, owing to the sulphuret being solu-
ble in an excess of sulphuretted hydrogen.
An essential step  in the  process, there-
fore,  is to expel  that excess by  boiling;
upon  which a distinct precipitate,  and co-
lourless fluid are produced."   " if the sul-
phuret  after  boiling,  does  not  subside
easily, it is often useful to add a little mu-
riate  of ammonia to the fluid; and if the
fluid still continues muddy, and the depo-
sition be not complete,  it is right  to leave
it at rest for forty-eight hours or upwards."
After  the  supernatant liquid  has been
withdrawn, the remainder is poured upon
a filter, and when dry enough to admit of
it, the  filter  is to be gently pressed be-
tween folds  of bibulous paper, so  as to fit
the mass for  removal by a penknife,  to a
watch-glass, in which it may be dried tho-
roughly before a  fire, or over a  vapour-
bath.   When the quantity is very small,
and adheres to the filter, it may be  washed
through with ammonia,  precipitated  by
the cautious addition of hydrochloric acid,
and dried on a watch-glass:  or it  may be
transferred to a tube, washed with warm
water, suffered to subside, and after draw-
ing off the  water, dried by  cautiously
heating the tube. The reduction is effect-
ed by placing the sulphuret in the bottom
of a sealed glass tube, and covering it with
black  flux, or with a mixture of two parts
of ignited carbonate of soda and  one of
recently prepared charcoal powder.
  In the introduction of the materials, a
glass funnel made ofa smaller tube serves
  vol. ii.           24
 to keep the recipient clean.   In  the ab-
 sence of that a good substitute  may be
 made of  hot-pressed letter-paper,  cut, not
 torn, and rolled up so as to form a funnel
 or groove.  Any obscuring dust should be
 wiped out, and care should be taken to re-
 move by bibulous paper,  or some cotton
 affixed to a wire, the moisture which rises
 when the process of reductive heating is
 commenced.   The upper part of the ma-
 terial should  be  heated  first and with a
 very small flame of a spirit-lamp.  After-
 wards the heat should be applied to the
 bottom of the tube, the flame having been
 previously enlarged  by raising  the wick.
   The crust  thus obtained may be more
 fully tested by oxidizing  it on Dr. Turn-
 er's  plan, or by subliming it from burn-
 ing charcoal and smelling it, or by putting
 a fragment into a little  ammoniated sul-
 phate of copper on a watch-glass, so as to
 produce, after some time, Scheele's green.
   One of the most  certain processes for
 the detection of arsenic  in organic  mix-
 tures, has been suggested by Mr. Vena
 bles,  in the  10th volume of the  London
 Medical Gazette, p. 118.   This  process
 will  detect equally well  any of the ar-
 senical preparations,  and by it, according
 to its author,  there will be procured the
 greatest possible quantity of the poison.
   " Boil the suspected matters with a fee-
 bly alkaline  solution, filter coarsely, boil
 with a sufficient quantity of nitric acid to
 destroy the organic matters, filter, render
 feebly alkaline by means of caustic pot-
 ash, add acetic acid in slight excess, filter,
 and pass through a current of sulphuretted
 hydrogen, separate  the  precipitated sul-
 phuret deflagrate with  nitre, dissolve in
 distilled water, and filter: the addition of
 nitrate of silver will now precipitate the
 arseniate  of  that metal in the form of a
 brick-red  powder,  which,  on  reduction
 with charcoal and boracic acid, parts with
 all  its arsenic."  This  process  is com-
 pounded of parts  of those of Rose and
 Christison,  to which Mr. Venables has
 added the conclusion by the silver  test.
 Though  tedious and very complex, it is
 perhaps the surest mode of getting at very
 minute quantities of the poison.  It is ne-
 cessary, in attempting to reduce  the ar-
 senic acid or its compounds, to urge the
 spirit-lamp flame by the  blow-pipe, as a
 full red heat  is requisite for  their  com-
 plete decomposition.
  The quantity of arsenic which may be
 detected by any one of the preceding pro-
 cesses,  is  exceedingly  minute.   Chris-
tison thus discovered the twentieth of a
grain, and we ourselves formed eight dis- 
278                          ARSENIC. (Toxicol.)
tinct crusts, in as many tubes, from a sin-
gle grain of sirsenic, deposited for several
weeks, in the stomach and intestines of a
dead subject.
  When by any process of reduction, in a
glass tube,  the metal is sublimed, the fol-
lowing phenomena  are  observed.   If the
heat is  slowly applied, there appears at
first a white ring of arsenious acid, placed
at some distance from  the  flame.  Soon
after, the  whiteness  disappears, and  an
umber,  and finally  a jet-black, shining
ring replaces  it  Nearer to the  flame,
subsequently appear, a few  metallic-look-
ing spangles,  which, rapidly increasing,
cover the whole surface, and form a blu-
ish-white metallic  crust  of considerable
splendor.   The metallic ring is often con-
tinuous  with the black one, though not
unfrequently there  is a visible portion of
unoccupied glass between them.  In some
instances,  there is only a black ring, and
in others, the upper part of the white ring
retains its  colour to the close of the ex-
periment ;  so that we may observe  in the
same tube,  a white,  a black, and a metallic
ring."   In  a very  felicitous experiment,
the arsenical ring is exclusively of a me-
tallic lustre, no black and no white crust
being apparent.
   As in some  cases where arsenic is pre-
sent, we have only a black  ring, its true
character becomes  a subject of interest.
It is not a little surprising to find in au-
thors, so few allusions to the black ring,
which is so commonly present.   Scheele
mentions in one place, that 'a shining
regulus was obtained mixed with a little
arsenic  and charcoal dust.''  Christison
says • whenever the dark crust begins to
form,' &c.   What he means by the ' dark
crust' is not  stated  in that place,  but
from  passages in  his  papers and those
of Paris and R. Phillips, we  may pre-
sume that they supposed  it to be car-
bonaceous.  Phillips says * it would save
the introduction of charcoal into the tube,
and prevent it  from being mistaken  for
sublimed arsenic.'   Christison  observes
(Edinb.  Med. and Surg. Journ.  XXII.
80.),  "a  black vapour rises,  and con-
denses  on  the tube.  This is charcoal,"
&c.  "The arsenic does  not begin  to
sublime  till  the  discharge of  carbona-
ceous vapour has  nearly ceased,  and it
always  condenses  lower  down."  Paris,
in his Pharmacologia, maintains  a like
opinion, and terms  the black ring " a film
of very finely divided charcoal."  Berze-
lius was the first to suspect the true char-
acter of the dark ring.   He  says, in  his
 Chimie, "  the suboxide is obtained in the
reduction of arsenic,  for that which sub-
limes in the first instance is the suboxide,
of which very thin coats show, by trans-
mitted light a brownish colour."   When
this great author treats  of sublimation, in
medico-legal questions, he does not even
advert to the  dark ring, so that a novice
in such matters must  be inevitably misled
by what on this  subject is termed the
highest authority.
  The purest  metallic arsenic  without
any  charcoal, wijl often present, when
heated in a tube, the  three  rings.   They
consist of white oxide, suboxide intermin-
gled with  white  oxide and metallic ar-
senic, and a pure metallic substance—the
last being  nearest to the flame,  and the
first at the greatest distance.
  After  describing the totality of these
phenomena, Christison declares that " it
may be safely laid down that  the  appear-
ances  exhibited by  a  well-formed.crust
are imitated by no substance  in nature;"
and Professor Silliman says that" the re-
duction of the arsenic  is perfectly deci-
sive, and,  if this proof is obtained, there
can be no mistake."   In a  paper  on this
subject in the Amer.  Joum. of the Med.
Sciences.  X.  126., we have  shown that
sulphuret of mercury  forms, when sub-
limed, appearances so similar to those by
arsenic,  that  the  three rings are often
seen of like colours  and in similar order.
" Even when the quantity used amounted
to several  grains,  the semblance  was so
strong as to deceive experienced chem-
ists."  The experimenter  should never
rest  satisfied,  until,  having extracted the
substance, he perceives  its metallic lustre,
when  rubbed  on clean paper, and smells
its arsenical odour, as it is thrown  up from
incandescent charcoal.
  The cinnabar stains the paper of a vermi-
lion hue, and its odour over burning char-
coal is sulphureous. A very scrupulous ob-
server will also oxidize a part, dissolve it in
clean water, and use the liquid tests point-
ed out in the chemical part of our article.
   Although in simple solutions, the liquid
tests afford unimpeachable  evidence, yet
in organic mixtures, they are scarcely en-
titled to  the slightest  attention. In no one
of the cases of poisoning examined in this
city, has the  poison  been rendered satis-
factorily evident by liquid tests.   In five
judicial  cases in which Professor Chris-
tison had to search for arsenic,  neither
ammoniacal nitrate of silver,  nor sulphate
of copper,  gave indications of its presence,
although unequivocally detected  by the
process of reduction by the aid of sulphu-
retted hydrogen. 
ARSENIC. (Toxicol.)
279
  The impediments are  of two kinds.
Some substances, not poisonous, afford pre-
cipitates  like those produced by arsenic;
while others prevent  the arsenic, even
when present, from being thrown down.
Thus, decoctions of crude coffee and  of
onions, cause  greenish precipitates with
sulphate  of copper;  and alkaline  phos-
phates react on the nitrate of silver so as
to produce a yellow precipitate.   Several
substances separate the sulphur from sul-
phuretted  hydrogen, and indeed such a
separation is sometimes spontaneous.   To
render the liquid tests, therefore, available
in such  cases, a great variety of precau-
tions has been  suggested.  It has been
proposed  by  Orfila to decolorize with
chlorine,  and  by Phillips, with animal
charcoal.   Marcet got rid of chloride  of
sodium by adding a little  nitric acid and
cautiously precipitating with lunar caus-
tic ; and Christison suggests the removal
of casein and albumen by acetic acid. But
it must  appear obvious to any one  ac-
quainted with the  subject  that most  of
these processes endanger the loss of a por-
tion of the arsenic, and that the substances
most likely to interfere with a conclusive
manifestation  of the presence of the poi-
son,  are  not  separable by  the indicated
means.   For  the  unprofitable  discussion
of this subject,  the curious reader is  re-
ferred to the  works on Medical Jurispru-
dence.
  It may not however, be useless to state
that the  reaction of the alkaline phos-
phates, and of arsenic, with nitrate of sil-
ver,  may be discriminated, by making the
experiments  with a few  drops, on white
paper.  The  colour,  at first nearly  the
same in both, remains for some time  un-
changed in the case of the arsenic, but it
gradually becomes brown and continues
so when dry.  The phosphate, in less than
two  minutes,  fades into a ' sad green,' be-
comes darker and darker, and finally quite
black.  The precipitate with arsenic  is
flocculent, whUe that by the phosphate is
of a homogeneous liquidity.
  Arsenite of Copper  is detected in  or-
ganic mixtures, by solution, by means  of
acetic acid and heat, filtration,  and preci-
pitation  by sulphuretted hydrogen.  The
sulphurets of copper and arsenic are sepa-
rable by  ammonia, which dissolves only
the  latter; and that is recoverable by hy-
drochloric acid.
  Arsenite and Arseniate of Potash are
separated from organic compounds, by the
same means as have been selected for the
detection of arsenious acid.
  The Sulphurets of Arsenic, being in-
soluble in most organic mixtures, may be
found not unfrequently in visible particles
in the contents of the stomach.  If in a
too finely divided state to be collected by
mechanical means, they may be dissolved
in an excess of ammonia, filtered, and pre-
cipitated by hydrochloric acid.
  The poisonous power of the prepara-
tions of arsenic  is probably in direct pro-
portion  to  their solubdity,   modified by
their tendency to pass into other and more
soluble forms.   Thus, regulus- of arsenic,
not itself deleterious, is so soon converted
into soluble oxides, as to seem noxious. In
the same way, sulphuret of arsenic was
found by Guibourt to have  no injurious
effects, whilst Orfila  caused by it  the
death of various animals, and that in some
cases even by  application   to external
wounds.    Decourdemauche  reconciles
these apparent contradictions by showing
that in  simple water, but more readily in
organic mixtures, the sulphurets react on
the  elements  of water,  and form oxides
of arsenic and sulphuretted hydrogen.  The
only truly innoxious compounds of arsenic
hitherto tried are arsenuret of tin, given
by Bayen and Deyeux, and a native  sul-
phuret of  iron  and  arsenic (mispickel),
administered by Renault.   Arsenuretted
hydrogen so diffusive and soluble, is, when
inhaled,  the most poisonous  compound of
arsenic.  Next to it may be placed arsenic
acid and soluble arseniates, arsenious acid
and the soluble arsenites.
   It is not easy  to determine the amount
of any poison capable of causing death;
as so much must depend on the subject, as
well as  the  circumstances  under which
administered.   The  smallest dose of the
arsenious acid,  known to have produced
death, was a solution of four and a half
grains,  taken by a child four years  old.
Estimating  the amount necessarily  de-
structive to an  adult by the usual rules
for the proportional  administration of re-
medies to children and adults, a full-grown
individual should perish under the effects
of from 20 to 30 grains.  Accordingly, the
smallest dose actually known to have kill-
ed an adult was 30 grains.   Hahnemann
alleges  that  four grains will kill  within
24 hours, and that even two grains may
destroy life in a longer period.  Renault
killed a large dog by means  of one grain;
and severe symptoms have  been excited
in human subjects by doses varying from
one half to one grain. Of the less soluble
compounds, much greater doses are requi-
site to the destruction of life.  Thus Ob- 
280
ARSENIC.  (Toxicol.)
fila caused the death of dogs by  doses
of the  sulphurets varying from 40 to 70
grains.
  The symptoms produced by poisonous
doses of arsenic, usually begin to show
themselves in from half an  hour  to an
hour, although  cases  have occurred  in
which they have appeared almost immedi-
ately ;  as on  taking a second cup of poi-
soned coffee, or before finishing the  soup;
and others in which several hours,  nay, a
whole  night, have intervened between the
reception of  the drug, and the develop-
ment of the symptoms.  In general,  the
speediest effects are produced on  empty
stomachs, and the slowest on those filled
with food, or holding some anodyne  medi-
cine.  The quiescent state of sleep seems
to make a singular resistance to the action
of this poison.  Mr. Edwards (Lond. Med.
and Phys. Journ.   XLIX.  117.) gives a
case where the  symptoms were manifest
in eight minutes: Bernt mentions that a
solution of arseniate of potash produced vi-
olent affections in fifteen  minutes. Chris-
tison's case  commenced in twenty min-
utes.   Mr. Macauly of Leicester, quoted
by  Christison,  had a patient who took
seven drachms of the  poison at 8 P.  M.,
went to bed at half-past 9, and slept until
11: M. Devergie states  a case of poison-
ing by the sulphuret where the symptoms
did not begin for three hours, and where
sleep intervened; and Orfila has noticed
an  instance of the  absence of symptoms
for five  hours.  The girl, Warden (Ed.
Med. and Surg. Journ.  XXVII.  450.),
took a white powder at ten P. M„ went to
bed and slept until six next morning, and
then began to exhibit symptoms of poison-
ing.   Marianne Warwick (Lond.  Med.
Journ. 1830.) took, about 12 o'clock, M.,
three ounces of laudanum and nearly two
drachms of arsenic,  yet " even to the hour
of her death,  excepting pain  in the bow-
els, complained  of once  or twice,  above
seven  hours  after  the poison  had  been
taken, there was no  symptom of poisoning
by  arsenic."  Death,  in  this  case,  arose
from laudanum; although, notwithstand-
ing the immense dose,  four hours elapsed
before any signs of  narcotic influence  be-
came decidedly apparent.  In the case of
Kesler's wife, quoted by Dr. Beck, opium
and arsenic appear to have been  given
either simultaneously or alternately; and
although  a considerable quantity of opium
was, after death, found in her stomach,
the fatal issue seems to have been caused
exclusively by arsenic.   The opium ap-
pears to have produced occasional drowsi-
ness, and to have  retarded the action of
the arsenic.
   The duration of life after taking a fatal
dose of arsenic, is as various as the period
which elapses before the manifestation of
the symptoms of poisoning.  Mr. Brodie
killed a dog in fifty minutes, by injecting
a  solution of arsenious acid into its sto-
mach.  The effects were narcotic.   The
shortest recorded case of death by arsenic,
is one related by Pyl, in which the poison
proved fatal in three hours.  Death  from
arsenic has happened after 3^, 4,5,6, &c.
hours—most commonly, in from 24 hours
to two or three days; and in a few in-
stances, patients have died after an  inef-
fectual struggle of weeks or even months.
When death  is suddenly produced,  the
symptoms are either those of a narcotized
system, or, much more commonly, such as
indicate great disorder of the  circulation.
When death is caused after a day or two,
the  signs of irritation or inflammation of
the prima via are. usually  most promi-
nent ; and when the  fatal issue  is greatly
prolonged, the patient  suffers most  from
affections  of  the  great  nervous masse?,
manifested by tremors, paralysis, convul-
sions, &c.  There is, however, so little
uniformity in the action  of arsenic, that
cases may be cited in which the nervous
symptoms presented themselves in  the
most acute attacks, and where violent in-
dications  of  inflammation  were present,
when the subjects survived only five or
six hours.  It is therefore possible to meet
with all  the great symptoms of the va-
rious stages,  in  one  case,  and at one
time.
   The ordinary symptoms of  arsenical
impression are, at first, a sense of weight
and oppression about the pracordia. Then
ensues, a fiery pain at the stomach, with
nausea, vomiting, and faintness.  The pain
is increased  by  pressure,  and there is
sometimes either  diarrhoea or tenesmus,
with  the  occasional evacuation of bloody
mucus.  Not unfrequently, hoarseness and
difficulty of speech are observed, and such
a degree of dryness and heat in the throat,
as to cause a  sense of suffocation, and a
shortness of breath. When the lower bow-
els are much affected, there is excoriation
of the anus, and the urinary and genital
organs are sometimes also attacked. After
a time, tremors and twitches, with spasms
of the arms and legs, increase the suffer-
ings of the patient.   In general, the cir-
culation is very hurried,  irregular,  and
feeble, attended with coldness, clammy
sweats, and even lividness  of the remote 
ARSENIC. (Toxicol.)                          281
extremities.  In such cases, death occurs
in from one to three days.
   When the fatal period is prolonged be-
yond one day, there is frequently a remis-
sion of nearly all the symptoms; but after
a deceitful calm,  the  disease recurs with
increased violence. Should death be post-
poned  to a still later period, the signs of
nervous disorder become more conspicuous.
Every stage of irritation may ensue, from
the most violent convulsions to entire pa-
ralysis.  Local palsy  is perhaps  more fre-
quent  than any other  indirect effect of ar-
senic.   Lively pictures are presented  by
different cases, of hysteria, epilepsy, tris-
mus.   Sometimes the cutaneous capilla-
ries are engorged, and the surface be-
comes tumefied, more particularly in loose-
ly constructed parts,  such as  the  eye-
lids and scrotum, and there  occasionally
ensues a desquamation of  the cuticle.
At other times,  the blood  flows inwards,
and a cold, shrunken, livid surface, marks
the approach of collapse. The moral state
varies from a perfectly collected condition,
to that of delirium, or coma.
   The peculiarities which frequently at-
tend arsenicated subjects, are  curiously
varied.  In some cases, there is, from be-
ginning to end, an entire  exemption from
pain.  In others, nausea and vomiting are
not observed.  In a  few cases, narcotic
effects have  almost immediately followed
the administration of the poison, whUe in
the greater number,  the  faculties of the
mind  are obscured solely by the progress
of physical dissolution, and are sometimes
unimpaired up to the act of death.  Al-
though the pulse is  commonly hurried,
one or two cases are recorded in which it
became preternaturally slow.  Jaeger saw
a girl 12 years old who died by drinking
water which had stood on the black oxide
of arsenic.   She made no complaint of
pain, even when asked  about it, although
she retained her senses to the last, knew
the persons around her, and spontaneously
expressed  her wants.  Dr. Yelloly also
records a case (Ed. Med. and Surg. Journ.
V. 389.) of a boy 16 years of age, who
died  by poison,  perfectly collected, with-
out any tenderness of the abdomen, and
without pain either in  the  stomach or
bowels.   In Philadelphia, five persons si-
multaneously poisoned by arsenic, were,
all of them,  exempted from pain  in the
stomach and bowels.  Two out of the five
died, and the fatal cases were not affected
with vomiting, neither could they be made
to reject the contents  of the stomach by
any of the ordinary means.  In the Lon-
don Med.  and Phys. Journal,  XXXIV.
                 24*
there is related a case where death  en-
sued in about five hours, without vomiting,
even although emetics were given.
  Cases exemplifying almost every irre-
gularity of the circulatory, digestive, and
nervous systems, and a singular variety
of disorder of the urinary, genital, mus-
cular, and moral functions, might be cited,
but  that would  unnecessarily extend  an
essentially prolonged  paper. The medical
jurist will now be sufficiently on his guard,
and must feel convinced that while he re-
cognizes as arsenical,  a certain  set  of
symptoms, he will not  infer the  absence
of the poison, because  these symptoms are
wanting;  nor  will he decide against  its
presence in the system, solely because a
totally opposite condition may be present-
ed by  the  patient.  It  seldom, however,
happens that arsenic  produces  such a se-
ries  of phenomena as may be ascribed to
any  known disease; and a well-educated
physician could,  in our day, hardly fail to
have his suspicions awakened by the symp-
toms of the whole case, however anoma-
lous these symptoms might be.  Only the
cold plague  (congestive fever)  of  our
south-western country, the epidemic cho-
lera, and  yellow fever,  ever  present a
combination of phenomena such as might
be produced by arsenic. But they are  epi-
demics ; and they have all of them addi-
tional  peculiarities which enable  a  dis-
cerning physician to  recognize them, or
they resemble the arsenicated cases only
in a part of their course.  We may, after
poison, observe the burning pain, and floc-
culent vomit of yellow fever; but the lat-
ter presents the yellow skin, in fatal cases,
while the former, in such instances, is al-
most uniformly accompanied by pain  and
spasm  of the  extremities.   In  the  poison
case, too,  the  intestinal evacuations, com-
pared with those of yellow fever, are very
distinctive.  In those  violent cases resem-
bling cold plague, the arsenical case  ter-
minates much more  rapidly, is accompa-
nied with less cerebral irritation, and more
irregularity of circulation, and is very sel-
dom without a distinctive condition  of the
stomach and intestines. It is, however, with
Asiatic cholera, that violent arsenical  poi-
soning is most likely to be confounded. The
suddenness of the attack, the pain, spasms,
nausea, vomiting, collapse,  and speedy
death, are circumstances of both diseases;
but  the extreme lividness of fatal cases
of cholera, together with their farina-like
evacuations, and the  absence commonly,
of bloody  effusions, may generally serve
fully to discriminate  them.  When  the
poison-case is protracted, and exhibits both 
282                          ARSENIC.  (Toxicol.)
the inflammatory and nervous stages, the
distinguishing marks become so numerous
and characteristic as to leave not much
doubt of their origination.  Still, however
distinctive may be the  signs of such a
case,  no man who regards as he should
do, the uncertainty and imperfection of
human  knowledge, will suffer them to
convince him of the  existence of a  poi-
sonous cause.  Their only legitimate ef-
fect should be to arouse his attention, ex-
cite his suspicions, and lead him to a fuller
and more critical examination of all the
evidence that the case has given, or may
be made to give.
   Under such  circumstances, he will en-
deavour to procure all the remains of the
medicine and food, collect the evacuations
from  the  stomach and bowels, and care-
fully  but  unobtrusively investigate  the
probable motives for, and  effects of, the
destruction  of his  patient.  But a  still
more  important duty consists in a careful
autopsy, with a view to the observation of
the internal  changes, and the collection
of the materials  for chemical investiga-
tion.  In  the most acute  cases, the ob-
servable effects, if any,  are usually  con-
fined  to the  distribution and condition of
the blood. In the more ordinary instances,
the organic lesions are  mainly discover-
able in the  gastro-intestinal surface;  and
in very protracted  examples, signs  may
be found of the alteration of the structure
of the brain and spinal marrow.
   Post-mortem appearances.  As in very
acute cases of poisoning, the blood is often
found dark and liquid, the dependent parts
of the body must frequently present accu-
mulations of that  fluid.   For the same
reason,  petechia have been observed in
less dependent places, both on the exter-
nal surface and that of the inner face of
the hollow viscera.   The heart has  been
found filled with black fluid blood gene-
rally  mixed  with some  flocculi, and, as
might be expected, the great veins espe-
cially of the abdomen  were  constantly
turgid with  black blood.   The  internal
face of the blood-vessels and heart are sel-
dom  found  altered in hue or structure.
Rarely, spots of a sanguine colour may be
seen.   In a case examined by Orfila, the
cavities of the left side of the heart had a
mottled hue, and the ventricles displayed
crimson spots which  extended  into the
muscular  tissue. Godard makes a similar
observation, and Orfila observed the same
phenomena in animals.   As these appear-
ances are not  always  6een after death
from  arsenic,  and may be  produced by
many other causes,  they ought  to  have
weight  only when combined with other
testimony.   In a very few cases, the blood
coagulates,  and exhibits an  arterial hue.
The alteration in the state  and  distribu-
tion of the blood is most observable in those
very acute cases in which no organic le-
sions  are discoverable, and  where death
seems to be produced  solely by the de-
struction  of the function of circulation,
and its necessary consequences.   But the
same  disorder  of the blood and its canals
is  observable in less  rapid  cases.  The
lungs are  sometimes  found  highly con-
gested.   In other  cases they appear per-
fectly natural.  Jaeger  observed  extra-
vasated blood in the lungs in certain cases,
but never found it out of its proper ves-
sels, in any other organ.  Blood has been
seen  by others, in almost  every hollow
viscus, and also interstitially deposited, in
various  places, especially  between  the
different coats of the  stomach and intes-
tines.
 The congestion and inflammation caused
by arsenic, wherever applied, whether ex
ternally or internally, are most frequently
and  most  extensively found along  the
course of the  alimentary  canal.   Accord-
ing to Jaeger, the stomach and rectum
suffer most; but in the latter position he
is  not sustained by other authority.  As
might naturally be expected, the stomach
is, in  cases of internal poisoning, the most
manifest seat of inflammation,  and next
to  that,  the small intestines,  it is chiefly
in  cases protracted, or in those destroyed
by repetitions of the poison, that the large
intestines exhibit  the inflammatory phe-
nomena.  But in  this,  as in all other re-
spects, arsenicated patients are subject to
no well-defined rule.   When arsenic has
caused  death even by external applica-
tion,  the alimentary canal has  exhibited
the severest proofs of its action, and in
such  cases the stomach and small intes-
tines  have been chiefly affected.  The in-
flammation  is  manifested in various de-
grees.  A slight blush is  all  that is some-
times perceptible.  In other cases  is dis-
played every shade of colour, from a bright
scarlet to melanotic blackness, with every
state  of the mucous coat,  from thickening
and hardening or softening, to the attenu-
ation and even entire removal of parts of
it  In  a very few cases,  holes have been
made, through all the alimentary coats.
Whenever these  apertures are produced
by poison, they are  surrounded by marks
of inflammation; whilst the erosions which
are caused after  death  by  any solvent, 
ARSENIC. (Toxicol.)                          283
such as the gastric juice,  are unaccompa-
nied by  sanguineous discoloration, or in-
creased vascularity.
   As there are no  changes of structure
peculiarly  effected  by  arsenic, it seems
scarcely necessary to enter into a minute
detail of the morbid phenomena observed
in various instances.  As they are always
the result,  not  of  the direct action of the
mineral, but of the  inflammation  created
by it, the same effects may be  traced to
phlogosis  excited by  any other  active
cau3e.  Possibly  there may arise pecu-
liarity of appearance from the commin-
gling of irritation and diminished  vitality
in a part   When arsenic excites gene-
rally the vascular power of the  gastric
surface, and suddenly reduces the  energy
of vitality  in  the parts  with  which it
comes into  more  immediate contact we
might expect to find such parts discoloured
by dark blood, or elevated by its effusion.
In a case of poisoning by corrosive subli-
mate, these patches of blackness were ob-
served by us where the  poison was col-
lected  in the greatest quantity.   Chris-
tison makes the  following observations
on such phenomena, which he says " there
is strong reason  to  believe, always indi-
cate some violent irritation at least if not
even irritation from poison only, in the
organ where it is found. It is the effusion
under the villous coat of the stomach, and
incorporation with its substance, of dark
brownish black, or,  as it were, charred
blood; which is thus altered either by the
chemical action of the poison, or by a vital
process.  In many  cases of poisoning with
the mineral acids, oxalic acid, arsenic, cor-
rosive sublimate, and the like, there are
found on the villous  coat  of the stomach,
little knots, and larger irregular patches
and streaks, not of a reddish brown, red-
dish  black,  or violaceous hue, like pseudo-
morbid  redness, but dark-grayish-b\ack,
or brownish-black, like the colour  of coal
or melanosis, accompanied, too, with ele-
vation  of the membrane,  frequently with
abrasion on the middle of the patches, and
surrounded by vascularity. This conjunc-
tion  of appearances, I have never seen in
the stomach, unless it had been violently
irritated; and several experienced patho-
logists of my acquaintance agree with me
in this statement.  It bears a pretty close
resemblance to melanosis  of the stomach;
but is distinguished by the melanotic black-
ness being  arranged  in  regular  abruptly-
defined spots, and still better by melanosis
not being preceded by symptoms of irrita-
tion  in the stomach.   I must express my
doubts  whether the  appearances (in the
stomach) now described, ever arise in this
country from  natural disease.  In the in-
testines, they are sufficiently familiar to
the physician, as  arising from idiopathic
enteritis, and from dysentery.   But in the
stomach, their existence, as the effect of
natural disease, is doubtful." 2d ed. p. 120.
   The  assertion,  limitation,  and partial
retraction  of  opinion,  in  the foregoing
paragraph, show  how  impossible is the
certain discrimination of the  effects of
arsenic from those of disease.   Each wri-
ter, in his turn, condemns the distinctive
marks assumed  by his  predecessors, and
himself selects new ones, subject by his
own authority, to so many exceptions and
corrections, as to render them practically
useless.  All that can  be  safely said is,
that when, in the absence of  epidemic
cholera, cold plague, or yellow fever, there
arise, without apparent  cause, symptoms
of great irritation of the alimentary ca-
nal, followed by death, and the exhibition
of inflammatory marks  in  the  stomach,
small intestines, and rectum,  especially
such as are pointed out in the paragraph
quoted, the physician should feel bound to
go into a private examination of the poi-
son-question;  but  not without  other col-
lateral, or  still more direct proofs of poi-
son, venture  to  raise   public  suspicion.
While from a  timid, ignorant, or culpable
course, on  his part, wrong may have been
permitted to go unquestioned,  much  more
frequently  character,  nay, sometimes life,
has been sacrificed to ill-judged and un-
just charges of crime.   It is always best
to call in  a confidential medical friend,
and candidly discuss with him the grounds
of suspicion,  and determine, rather on a
survey of the  whole question, than  on a
partial  and  ill-instructed  investigation.
  Although in general the detection of the
poison itself,  as well as the evidence of
such a death as such a poison would pro-
duce, are essential  to the verdict of " death
by poison," yet cases do occur in which
the discovery of poison in the body, or
after its  ejection from it is not necessary
to such  a conclusion.   Along with the
symptoms,  and post-mortem phenomena,
there may coexist such motives  and such
conduct on the part of others, as to make
a  public  examination  obligatory,   even
when no poison can be  detected.   Such
circumstances existed in the case which
led to the trial of Lucretia Chapman and
Espos Y. Mina, for  the murder of the
Rev. William Chapman.  In that case, the
motives  for  the deed  were  previously
avowed, the symptoms were such as ar-
senic  might produce,  the  funeral  was 
284
ARSENIC.  (Toxicol.)
hastily made, and the parties implicated
in the charge were married in nine days
after the death  of the husband of one  of
them.  During the illness of Chapman,
there was shown an unwillingness to send
for medical aid, and a neglect of medical
orders when given.  In  an  intercepted
letter from Mrs. C, expressions of a mys-
terious character led  to suspicion on the
part of the  public authorities of the city
of Philadelphia,  which  on inquiry was
strengthened by  the  voice of the neigh-
bourhood.  The disinterred body afforded
corroborative testimony, and although no
arsenic was found, the peculiar odour  of
that substance  was made apparent.  On
the whole chain  of events, the medical
witnesses founded a declaration of belief
in a  poisonous cause of death,  and that
poison arsenic.   That opinion  was farther
confirmed by the discovery that Mina, one
of the suspected parties, had purchased a
large quantity of arsenic, on the very day
before the illness of Mr. Chapman.  That
illness came on suddenly after  eating of
customary food, of which no other part of
the family partook.
   The case of Abraham Kesler (Beck's
Med. Jur.)  was also  circumstantial, and
the conviction  obtained, without the de-
monstration of the presence  of arsenic.
Its presence was rendered probable by the
concurrence of  the evidence of various
experiments, though  none of them con-
clusively proved  its existence.   In such
cases, the physicians  are bound to pursue
the subject  to the confirmation or refuta-
tion of the suspicions naturally created by
the obvious  phenomena.
   Medical jurists have agitated the ques-
tion of the  evidence  of the  introduction
of poison after death, with a  view to the
inculpation of innocent persons, or the ac-
complishment of some other criminal de-
sign.   Orfila  alleges  the  existence  of
such  attempts, but cites no  particulars.
   In such cases, the mucous membrane is
altered solely  where  the poison  comes
into actual contact with it, so as to create
abrupt  and  well-defined marks.   These
are of a bright red colour, with a dark ex-
travasation  here  and  there when the poi-
son is arsenic, and that applied immedi-
ately after death.  When the  application
is made twenty-four hours after death, the
spots are of a dark colour.  Such appear-
ances were  produced  by Orfila when he
injected  arsenic into  the rectum.  They
are, he thinks,  readily distinguished from
the diffusive irregular  inflammation cre-
ated  during life, which, instead of being
abruptly defined,  is gradually merged in
the healthy structure around it.
  The suspicion of death by poison is not
always felt immediately on the demise of
a person whose case may be made long
afterwards the subject  of legal investiga-
tion.  The secret thoughts of the attend-
ants reach slowly the knowledge of the
proper authorities; and in some instances,
the attention of the law is directed to the
case by the  course of  subsequent events.
It then becomes necessary to disinter the
body.
  The preservative effects of arsenic have
been  made  the subject of many experi-
ments and  much observation.  On the
whole, the evidence is at present rather
in favour of the affirmative, although a
good  set  of comparative  experiments is
yet wanting to decide  fully the merits of
a point highly important to society.  The
German  toxicologists,  with whom origin-
ated the idea of a peculiar antiseptic pow-
er in arsenic, are almost all  of them dis-
posed to consider the opinion in its favour
as settled.  The medical Inspector at Ber-
lin, Dr. Welper, in 1803, first  directed
public attention  to  this  subject.   Two
bodies, supposed to have been poisoned,
were disinterred after periods of half a
year, and two years and a half, respective-
ly,  and were found by him to be not pu-
trid, but dried up,  with  here and there
gangrenous-looking specks on the inner
surface of the  stomach.   In  these cases,
arsenic was  not  found.   His friend, Dr.
Klanck, pursued the subject  by making a
number of experiments on animals, which
resulted  in  the declaration, that  arsenic,
given internally, preserved not only the
surfaces  with which it came in  contact,
but the whole animal frame.  Many of
the bodies continued dry and without de-
cay, after the lapse of three  years.  The
facts  on  this question, next in order of
time, are those at Bayreuth in  Bavaria,
where poisoned  bodies disinterred  after
five, six,  and fourteen months, were found
not decayed, but hard.   In two cases, the
stomach and intestines were  so firm as to
permit all the usual treatment  of a  strict
mechanical  investigation.   In one only of
these cases, arsenic was not detected.
  Dr. Kelch,  in Hufeland's Journal,
mentions  the curious preservation of the
stomach  and intestines of a  poisoned hu-
man subject for five  months after inter-
ment although the body itself had begun
to putrefy before  burial.  They preserved
all  their colour,  lustre, and  consistency.
They had a peculiar smell. A great num- 
ARSENIC.  (Toxicol.)
285
ber of cases might be cited, most of them
confirmatory of the antiseptic powers of
arsenic.   For these, the curious inquirer
is referred to the works on medical juris-
prudence and  toxicology,  particularly to
that of Christison.
   Kesler's wife  (Beck) was disinterred
two months  after her decease.   "Putre-
faction was far advanced, and the surface
of the body was of a dark colour, particu-
larly on the  abdomen.   The stomach and
intestines were in a highly inflamed state,"
&.c.   In  this case, no notice is taken di-
rectly, of the state of preservation of the
stomach; but as the appearances produced
by inflammation were  cognizable, it is to
be supposed  that they had not participated
in the general  putrefaction.
   William Chapman, whose case has been
already alluded to, was interred  on  the
23d of June, and disinterred on the 23d
of September.   Before his  interment and
almost immediately after death, a putre-
factive smell was observed  by some of the
attendants;  but when taken out of the
ground, after a lapse of three months, al-
though the face was black  and putrid, the
abdomen  and chest were of a pale white
appearance, and resisted the knife so much
as to  attract Dr. Hopkinson's particular
attention.  "No offensive  odour escaped
from the abdomen." The intestines seem-
ed disposed  rather to become dry than to
putrefy.
   Clara Ann Smith, poisoned by commer-
cial orpiment, at Bristol, England, on the
23d of October, 1833, was disinhumed on
the 24th December, 1834, fourteen months
afterwards.   This body,  like that of Mr.
Chapman, had sustained   the   greatest
change on the anterior part of  the head.
" The  eyes were sunk  in,  and the lower
part of the nose and lips had fallen.  The
pharynx,  tongue and surrounding parts,
were much  decomposed."   The  integu-
ments of the thorax and abdomen were
converted into adipocire. The diaphragm
was extremely firm,  the   heart much
shrunk, the lungs shrivelled and reduced
to the size of  a man's hand, the stomach
and intestines almost empty and flat and
all these viscera were as little altered as
" in a person who had died  a few days be-
fore in cold weather."
   The writer of this article put a grain
of arsenious  acid combined  with  potash,
into the stomach  and part of the intes-
tines of a man, who died at the  Philadel-
phia Almshouse.  These viscera  were ex-
posed for  nearly three months to the air
of the  laboratory, did not putrefy in that
time, became much drier, and gave out an
odour exactly like that of William Chap-
man's  stomach.   It was nearly identical
with the smell of dried red herrings.
  The  number  of examples of the pre-
servation of the poisoned organs, is quite
sufficient to show that arsenic  possesses
high antiseptic qualities; and the natural-
ist, who has long been aware of the fact
avails himself of it to secure his dry pre-
parations.  But there is also at least some
ground for  believing,  that  this singular
mineral exerts, although less potently, a
protecting influence  over  even remote
parts of a body which  has been destroyed
by it   We can explain this solely by sup-
posing the production of arsenuretted hy-
drogen, and its penetration into  the solid
tissues.  This is rendered probable by the
fact that putrefaction usually makes a be-
ginning soon after death, but  is subse-
quently arrested.
  A few examples of accelerated decom-
position in well-established cases of death
by means of arsenic, do not invalidate the
general truth.   They only  serve  to  put
the inquirer on  his guard, and to  show,
that in  this particular, as in all others, ar-
senic is subject to no certain rule of action.
  Every part of the body admits the poi-
sonous  influence of arsenic.  By the nose,
rectum,  vagina,  cuticle of  the  scalp,
wounds and abrasions of other parts  of
the surface, the deadly energy of this
drug has  found access to the  sources  of
life. But  its apparent effects have usually
been in all cases alike, and its manifesta-
tions have been  chiefly  observed  in  the
alimentary canal.
  Death  was produced in a young man
who treated an itchy eruption with an ar-
senical ointment.  (Lusitanus.)  A girl
was killed by applying a similar prepara-
tion to psoriasis.  (Wepfer.)    Zittman
reports the  death of two children by  an
arsenical  solution applied to  the scalp.
Many cases of destruction by arsenic ap-
plied to ulcers, and a much greater num-
ber of  hurtless applications of the same
kind, are quoted  by authors.  Two causes
are assigned for this discrepancy.  Black-
adder  found that a  large quantity pro-
duced  no injury; and  supposed therefore
that it  acted so  powerfully  as to destroy
the function in the part, by which a lesser
quantity might be introduced into the sys-
tem.  Harles supposes  the difference to
be dependent on the integrity of the blood-
vessels of the part, and that the danger is
always  great when  there are  patulous
veins on the part.
  Fodere relates a case of rectal poison-
ing; and  in Ansiaulx, and in  Henke's 
286                          ARSENIC. (Toxicol.)
Zeitschrift, &c, two instances are quoted
of the destruction of life by the introduc-
tion of arsenic into the vagina.
  The skin of the lower animals is less
easily affected by arsenic than that of the
human species.  Hence Jaeger thought
that this  poison did not operate through
sound  integuments,  and  Renault denied
its power of doing more than to form an
eschar, or a pustular eruption.  But a num-
ber of persons in Germany were severely
affected by using  arsenic by  mistake for
hair-powder, and  one of them  died.   A
case of a remarkably arsenical  character
is related by Desgranges, in which a wo-
man used, for the extirpation of lice, an
ointment made of lard and arsenic.   She
had erysipelas of the scalp, inflammation
of the  eyes, and enlargement of the neigh-
bouring  salivary and  lymphatic glands.
But, what must greatly interest  the toxi-
cologist, she suffered from fever, delirium,
vertigo, syncope, pain in the epigastrium,
nausea and vomiting, tenesmus, irritation
of the genito-urinal organs, and tremors
of the extremities.
  The Treatment of cases produced by
the poison of  arsenic, must from the va-
riety of its action, be  greatly diversified.
The first care of the physician,  should be
the elimination, as far as possible, of the
morbific  cause.  Emetics have  been se-
lected chiefly  for their celerity  of action,
and therefore mustard and water, hot salt
water, solutions of sulphate of copper or
zinc, ipecacuanha, and the stomach-pump,
have been preferred.  Unless,  however,
the poison has, as rarely happens,  been
given in solution, the greater part will re-
main in the stomach, and resist every pro-
per effort  for its removal.
  This fact makes the discovery of an an-
tidote highly desirable.   Three classes of
antidotes have been  suggested.  One, the
viscid, oily, or mucilaginous  substances,
which are supposed to envelope the ar-
senical particles, and  obtund, or entirely
prevent their  poisonous action.  When
these are swallowed almost instantly, they
may do good; for it has been  often ob-
served that such substances,  or, indeed,
ordinary articles of food, taken along with
arsenic, greatly impede its action.   They
are usually given,  however,  too  late, and
if relied on, do injury by excluding or in-
terrupting the action of better means of
cure.   Of the demulcents,  milk is  gene-
rally preferred, although gum-water, or
any mucilage,  will be found  nearly if not
quite as efficacious. The oils do  injury by
protecting the  arsenic from the action of
the chemical ajents to be presently no-
ticed, and are thought by some authors to
augment the  poisonous power of the  ar-
senic.
   The second class of counteractives con-
sists of substances chemically inactive as
respects arsenic, but which have at vari-
ous  times  possessed some  reputation as
antidotes.  The chief of these are magne-
sia and charcoal, both of which are, at
present, very properly disregarded.
   The  substances which render less  ac-
tive, or entirely inactive, the more poi-
sonous compounds of arsenic, are more to
be relied on.  As arsenites of the alkalies
are believed to be less active than arseni-
ous acid, alkaline solutions have been used
remedially. For the same reason, sulphu-
ret of potash, lime-water, and sulphuret-
ted hydrogen, have been recommended,
with a view to the production of insoluble
compounds of arsenic.  We have already
seen that these compounds are fatal.  Of
late, hydrated peroxide of  iron has been
confidently appealed to for the production
of a perfectly insoluble and totally inert
arsenite of iron.  Drs. Bunsen and Ber-
thold, oe Gottingen, who suggested this
counteractive,  make it by adding nitric
acid to a heated solution of protosulphate
of iron, precipitating by an  excess of am-
monia,  and washing the  precipitated ox-
ide.  The  cases cited by the discoverers,
as well as those by Soubeiran and others,
eminent in this department of medicine,
were apparently conclusive on the side of
the antidote.  Very recently (Journ. Heb-
dom. des Progres, &c, for March, 1835.),
M. Bouley, Jr.  presented to  the French
Academy of Medicine, an  essay on this
subject.   From  numerous  experiments
made on horses, the author believes him-
self entitled to  assert,  that when a suffi-
cient quantity of hydrated peroxide of iron
is given along  with arsenious acid, the
poisonous effects are  entirely suppressed;
that some benefit results from its use even
four hours after the  reception of the  poi-
son,  and that,  at a  later period,  it ceases
to exert any beneficial agency.   He also
discovered that neither the oxide, nor the
sulphate of iron, could control the poison-
ous action of arseniate of potash.  M. Bou-
ley insists much on the  necessity of  ad-
ministering the ferruginous  counteractive
in large doses.
  Indeed, the substances supposed  to lessen
in any way the activity of the poison, should
be given in large doses, and administered
as well by the rectum as the mouth. When
applied per anum,  they should be thrown
as high into the intestinal canal  as possi-
ble, by means of a long  elastic  tube  at- 
                             ARSENIC.

tached to the apparatus.   If arsenic is li-
able to be absorbed, the use of these agents
will be greatest at the earliest period.  At
a later hour, they may not find access to
the absorbed part of the poison; but they
will beneficially alter that which is left in
the stomach and intestines.
  After the  evacuation or transformation
of the poison, or even while measures for
these ends are in progress, the physician
may be required to sustain the patient un-
der the depressing action on the circula-
tion, or the irritation of the great nervous
centres, or  to allay the inflammation of
the gastro-intestinal surface.   Not  unfre-
quently, the prostration and inflammation
are so coincident as greatly to embarrass
the practitioner by the contra-indications.
Or the expectation of the inflammatory
stage, will restrain him in the  use of in-
ternal stimulants, during the antecedent
threat of collapse.  In either case, it must
appear proper to prefer external incitants,
or such as  have no  great power of cre-
ating  gastric irritation.   Sinapisms,  fo-
mentations, and frictions,  combined, if ne-
cessary, with wine whey, or camphor, or
opium, are solely admissible.  Blisters, at
least when large, increase the mucous in-
flammations.  In the greatest emergency,
the depression must be met by more decided
stimulants; but the  assistant must never
forget that the preparations of a less solu-
ble character are, some of them, dissolved
by ammonia, which is therefore to be  ex-
cluded from practice in such cases.
  Most commonly, the more urgent symp-
toms are those of inflammation of the gas-
tro-intestinal  surface.  Cold  demulcents
internally, and leeches and revulsive fo-
mentations  externally, are  chiefly indi-
cated, after the appearance of inflamma-
tion.   The  nausea may  be  palliated by
lime-water  and milk;  the diarrhoea, by
anodyne and mucilaginous injections; and
the pain, by anodyne frictions to the spine.
In  the cases showing  a cephalic  deter-
mination, the opiates will be of  course
avoided.   On the whole, the treatment of
the inflammatory effects  of arsenic is the
same as that for cholera, gastritis, and se-
vere diarrhoea, to which articles the reader
is referred,  for a fuller view of the man-
agement  Under the heads of Meningitis,
Apoplexy, &c, he  will find the means in-
dicated for the cure of those cases  of poi-
soning which show cephalic  symptoms.
  Opium has been  sometimes taken along
with arsenic, and has always either over-
come or postponed the arsenical influence.
In these instances, the  opium acted as
a feeble narcotic,  being apparently  re-
(Toxicol.)                         287

duced in potency by the arsenical  power.
How  far  it may be  safely applied  as  a
counteractive  of the irritant and depress-
ing powers of arsenic, or a reductive of its
actual effects, remains yet to be  investi-
gated.
  Summary.  1. Care should be taken to
secure as much as possible of the mate-
rials to be examined.
  2. A strict method is to be  observed in
conducting the investigation, and nothing,
if possible, left  to  inference, or intrusted
to memory.
  3. The chemical investigation should
be directed at first to the contents of the
stomach, failing which, to those of the in-
testines;  and  if fruitless,  to  the  tissues
themselves.
  4. The best process for  the detection
of minute portions of arsenic, is  that of
Venables;  which is compounded  of parts
of those  of Rose, Berzelius, and Chris-
tison, with an original conclusion, by pre-
cipitating an  arseniate of silver,  from a
solution of arseniate of potash, by the ni-
trate of silver,  and reducing that by dry
charcoal and boracic acid.
  5.  In  cases of actual poisoning, very
seldom  are  the  liquid means of detection
successfully resorted to, until simple solu-
tions are made, by oxidizing the reduced
metal, and redissolving that in pure wa-
ter.  A very critical observer may choose
to take the additional trouble.
   6.  The organic  mixtures prevent suc-
cess  through  liquid processes, by colour-
ing the  precipitates deceptively,  by pre-
venting  precipitation, by affording preci-
pitates  not  arsenical,  but of an arsenical
appearance, and by causing losses which
may defeat the detection by reduction.
   7.  The preparations of arsenic are hurt-
ful, nearly, if not exactly, in proportion to
their solubility, added to their facility of
conversion into more  soluble compounds.
Arsenic  acid  and the soluble arseniates,
arsenious acid and  its  soluble compounds,
are the most active agents of destruction.
Common orpiment is  highly  noxious, be-
cause it  contains a large quantity of in-
termingled  arsenious acid; but any orpi-
ment is destructive, because it is  sponta-
neously convertible, in the stomach, into
sulphuretted hydrogen and arsenious acid.
Arsenuret of tin, and native sulphuret of
iron and arsenic (mispickel), are the only
insoluble products  of arsenic which have
been found hurtless.
  8. The least dose known to have  killed a
child, is four grains of white arsenic; the
least dose actually fatal to  an adult, was
between twenty and thirty grains.  Opt- 
288                       ARSENIC.  (Therapeutics.)
 nion has been given in favour of the de-
 structive power of much smaller doses.
   9. The ordinary symptoms of poisoning
 begin within an hour,  but  arsenic has re-
 mained unobserved in the  stomach for
 several hours.  The latter  effect has been
 attributed to the  intervention  of sleep, or
 the addition of a narcotic.
   10.  The death  of a poisoned  subject
 takes place at periods varying from three
 hours, to days,  weeks, or even months.
 Very sudden death is usually produced by
 action on the brain or heart; dissolution
 after half a day and within three  or  four
 days, arises from inflammation of the ali-
 mentary canal; and when  the fatal issue
 is remotely postponed, the  patient dies of
 what have been  called nervous disorders.
   11. The first symptoms of arsenication'
 are, usually,  nausea, vomiting, and burn-
 ing pain  at  the  epigastrium, sometimes
 attended by heat in the fauces.   But the
 variety  of phenomena  is very great, al-
 ways,  however,  within limits  which  a
 well-informed observer may  distinguish
 as arsenically-caused combinations. They
 are formed of irregularities of the circu-
 latory, digestive, nervous,  and  muscular
 systems, with occasional disorder of the
 dermoid surface.
   12.  The post-mortem  exhibits  some-
 times no marks of diseased structure, but
 generally there is found in the prima via
 inflammation and its effects, from a slight
 blush, to the deepest red or the most  me-
 lanotic blackness—from reticulated lymph
 on the  surface,  to effusion into and be-
 tween the alimentary coats—from soften-
 ing or hardening, or thickening or atten-
 uation,  of the  velvet-membrane,  to  the
 perforation not only of that but of all the
 walls of the  canal.  The surface is  sel-
 dom  altered, though at times blue spots
 are seen and  desquamation  of  the  cuticle
 observed.   The circulating  organs seldom
 indicate the cause of death.  At page  283
 of our article, may be found Christison's
 description of what he supposes charac-
 teristic marks of arsenical  action, which
 it may be proper to say are described as
 effects of mere disease, by Andral, in his
 observations on hyperemia  of the  gastro-
intestinal lining.
  13.  Arsenic introduced  immediately
after death, so as to lie in contact with
mucous membranes, reddens only the parts
touched,   making  abrupt  well-defined
marks.  After twenty-four  hours,  its  ap-
plication causes  solely similarly defined
dark spots.
  14.  The antiseptic  effects  of arsenic
are generally admitted to preserve parts
 in actual contact with it but the question
 of a remote and general protecting sway
 is yet sub judice, although most of the
 German  suid a few of the great authori-
 ties elsewhere are disposed to admit its
 existence.
   15. Arsenic is most speedily fatal when
 injected into the veins or when applied as
 a vapour to the bronchial tissue, or in so-
 lution  to  the  alimentary canal.  But it
 may destroy life by attacking any tissue,
 —from  the sound cuticle  to  the  lining
 membrane of the vagina, or the Schnei-
 derian expansion of the nose.
                      J. K. Mitchell.
   §  3.  Therapeutic  Application.   The
 energetic action of arsenic on the animal
 economy, and  its frequent deleterious in-
 fluences, have not deterred medical prac-
 titioners from resorting to its employment
 as a therapeutic  agent.  The  necessity
 felt  in all periods by the profession, of a
 resort to numerous substances endowed
 with the highest activity, manifests the
 intractable character of many of the mala-
 dies man is heir to.
   Arsenic entered  into  the  therapeutic
 resources of the Latin and Arabian prac-
 titioners.   It was, however,  rarely em-
 ployed by them, especially in internal ad-
 ministration.  They have left us  no posi-
 tive  information available in its practical
 employment   For the advantages to be
 derived from this agent in the treatment
 of disease,  we  are  indebted  entirely to
 modern authorities and quite recent expe-
 rience.
   The introduction of arsenic  into  the
 Materia Medica has not been accomplished
 without  opposition.  Many  of the conti-
 nental writers,  particularly amongst  the
 French, condemn its employment entirely
 —and  assert, that patients who have been
 treated by it die  in a  few months subse-
 quently, of phthisis or chronic  inflamma-
 tion  of some of the viscera.  Apprehen-
 sions of this character are  not without
 foundation, but they are greatly exagge-
 rated.   Clinical observations, by the best
 authorities in this country and Britain, es-
tablish the innocuousness of arsenic when
administered appropriately, and  the effi-
 cacy of its remedial properties when pre-
 scribed with skill and judgment.  It can-
not be  denied, however,  that arsenic, in
 its exhibition,  is  attended with hazard.
It is to be  resorted to only when other
means prove unavailing, and the organs
are in  a condition to tolerate its energetic
action.
   Physiological Phenomena.   The em-
pirical  employment  of so  powerful  an 
ARSENIC. (Therapeutics.)
289
agent without reference to its influences
on the organs, must be always a danger-
ous procedure.  It must be  adopted with
extreme  caution.  Rational therapeutics
or the determination of all the phenomena
induced in the organs, and their influence
in the curative operation, is the only safe-
guard against the dangers of heroic reme-
dies  and a perturbating treatment.  But
this has not been accomplished as yet for
arsenic.   The phenomena it excites have
not been observed with sufficient accuracy
—and in a spirit of rigid analysis.
  In excessive doses,  the symptoms are
confused and varied.   Phenomena  result-
ing from its direct action on an organ are
confounded, by the  rapidity with  which
they are developed, with those of a sec-
ondary character proceeding  from the
sympathies of the organs or their depend-
ence on the functions of each other.  The
properties of arsenic are so exceedingly
noxious to every organized structure, ve-
getable and animal—are so destructive  in
their influence to the movements produc-
tive  of vital  phenomena,  that,  in large
doses, vitality is extinguished immediately
without any of those intermediate actions
in the organs that constitute the therapeu-
tic  operations of medicines.  Poisoning
from arsenic furnishes but few indications
for  the  establishment  of  its therapeutic
mode of action on the  organs.   We can
draw from it no positive inductions as to
its methodus  medendi, or rules  for  its
practical employment
  When  administered  as  a therapeutic
agent, the effects of  the remedy are often
modified  by the  existing state of the or-
gans ; and symptoms belonging to the dis-
ease, but  aggravated by its inappropriate
employment  are frequently mistaken for
phenomena caused by the agent itself.
  To determine more accurately than had
previously been done, the effects resulting •
from arsenic, Harles  instituted a series
of curious and  interesting experiments
upon healthy adults.  To these persons  he
administered the article in doses of from
one-twelfth to one third of a grain; and
he observed in them the following pheno-
mena :
   An increased heat of the whole body,
the increase  being more or less sensible
according to the dose of arsenic.
  A slight sensation of heat in the throat,
extending down the  oesophagus as far as
the stomach.  This  ordinarily disappears
on the second or third day.
  A remarkable and almost constant in-
crease  of appetite.  The occurrence  of
this phenomenon had been pointed out be-
  vol. n.         25
fore, especially by Hecker, and has been
confirmed  by the observations of Biett
and Cazenave.   If the dose of the medi-
cine exceeds, however, one-eighth of a
grain, there is, on the contrary, according
to the experiments of Harles, loss of ap-
petite, with nausea, vomiting, &c.
   Thirst and more frequent alvine eva-
cuations, often alternating with constipa-
tion ; or the latter may occur alone.
   Increased secretion of urine and of the
cutaneous transpiration.
   More or less abundant salivation, in
some rare cases, and when the use of ar-
senic has been long continued.
   The pulse under  the influence of the
first doses of the medicine becomes some-
times soft and feeble, at others small and
frequent.   If the dose  is increased, the
pulse  augments in force  and frequency,
afterwards  again  decreases so as to pro-
duce,  according to Harles, a species of
remittent fever, but without regular type.
M. Biett has also observed in many cases
these changes in the pulse. (Diet, de Mid.
IV. 21.)
   After the  use  of  the arsenic has been
persevered in for some days,  the  com-
plexion assumes  a sallow hue, the eye-
lids are tumid, the feet and hands swell,
and a dropsical  tendency  is manifested,
with an  anemic aspect. Individuals who
labour  under predisposition  to  phthisis,
are affected with cough, and the threat-
ening symptoms of that disease  appear;
and  those  in whom  chronic  inflamma-
tions of  any of the internal organs ex-
ist, present an aggravation of their com-
plaints.  The irritative affections of the
stomach more particularly oppose the ad-
ministration  of" arsenic.  It immediately
increases the symptoms and deranges more
completely its functions.  I have found a
single drop of the solution of arseniate of
potassa, in an irritable stomach, to produce
nausea, vomiting, and thirst.  Arsenic in-
deed seems to exert  an especial action in
augmenting the irritability of the  stomach
and intestines.
   Taking,  as our guides for determining
the actions of arsenic, the most approved
observations, it may be inferred that it
causes two distinct phenomena in the eco-
nomy.  The first is a specific direct action
destructive of vitality  in  the  fluids and
solids.  It operates in this manner applied
to ulcerated  surfaces, and  introduced in
large doses into the economy.  In the lat-
ter case, the death  of the organ takes
place without a vital reaction, and in con-
sequence no pathological alteration of the
structure is to be detected. 
290                       ARSENIC.  (Therapeutics.)
   The second order of phenomena results
from the  vital  reaction  of the organic
structure—the protective means of the
economy—resisting the aggression of the
destructive agent protecting the organ
acted on, and producing the Operations for
the  elimination of the offending matter.
In this respect arsenic is always an irri-
tant exciting, according  to the dose ad-
ministered, an irritation  varying from a
light degree to the highest state  of disor-
ganizing inflammation.
   Therapeutic Principles.  The  physio-
logical  phenomena produced  by arsenic,
lead to the establishment of the following
general therapeutic principles for the re-
gulation of its practical employment: 1.
It is incompatible with  all affections  of
the internal organs, especially of the sto-
mach, of an inflammatory character,  whe-
ther acute or chronic.  2. It should not
be resorted to in the diseases of patients
having a predisposition to phthisis.   3. It
is to be used with  great discretion, or en-
tirely rejected, with individuals of feeble
constitution, with those whose powers  of
life have been debilitated by disease, in-
temperance, or other causes that have im-
paired the nutritive and assimilating func-
tions of the economy.  4. The dropsical
diathesis, and a tendency to anemia, are
counterindications to its employment  5.
In the lymphatic  and nervous tempera-
ments arsenic is not tolerated as freely as
in the sanguine, and is to be employed
with reserve.
  Practical Employment.  Experience has
demonstrated that  arsenic may  be  em-
ployed as a remedial agent in various af-
fections.   It is  administered internally,
and  is frequently  used externally as an
escarotic.
  In internal administration,  the  diseases
in which it has been prescribed with  most
advantage are, 1.  Paroxysmal Affections.
The febrile paroxysmal affections are those
in which arsenic has established its high-
est claims to confidence.   Intermittent fe-
ver had been successfully  treated  with ar-
senical preparations by the common peo-
ple of England and of Germany, before it
was ventured on by regular practitioners.
Slevoght and Frick, German physicians
of repute, obtained favourable results from
it in the  treatment of intermittents. (1700
-1710.)  Upwards of three hundred cases
are spoken of by them.  The Plenciz of
Vienna, father and son, after an extended
experience, concurred in similar testimony
to its safety and efficacy as a therapeutic
agent in  fevers.
  But  it is to Dr. Thomas Fowler that
 we  are indebted for  the more  general
 knowledge of the  utility to be  derived
 from arsenic in intermittents.  The testi-
 mony of Fowler was sustained  by Ar-
 nold, Withering, Willan, Pearson, and
 others, in England.  The experience of
 the  practitioners of  the United States
 equally proclaimed its salutary powers in
 intermittents.  The fact is now generally
 admitted—it cannot be  contested by the
 most prejudiced of its opponents.
   Though arsenic possesses undoubted ef-
 ficacy in the  cure  of intermittent fevers,
 it must not be considered as infallible, and
 regarded as a substitute  for cinchona and
 its preparations.  It frequently fails in ac-
 complishing a complete cure.  The same
 difficulty that is met with in this class of
 affections when managed by cinchona,—
 the  liability  to relapse—exists not  less
 when arsenic is employed. It is less gene-
 rally applicable also to   the  mass of pa-
 tients, and more of danger as regards its
 inappropriateness to the  constitution and
 general health  of the patient is to be ap-
 prehended.  There are many cases of in-
 termittents of recent occurrence,  and in
 individuals enjoying robust  health,  that
 may, ab origine, be treated by arsenic.
 But  it is preferable, as a general  rule, to
 rely on cinchonic preparations whose pow-
 ers and mode  of action are within the
 physiological limits of the organization.
 This circumstance forms the peculiar char-
 acteristic of the tonics, and renders them
 remedies of so much  importance  in the
 treatment of numerous diseases.
   Arsenic, from  its efficacy in intermit-
 tents, has been called a tonic.  No appel-
 lation  could be more  inappropriate.  No
 resemblance exists  between the physiolo-
 gical phenomena induced in the economy
 by tonics and by arsenic. The actions of the
 first are in the line  and within the limits
 of the healthy organic actions; they push
 these on to the  highest point  they can
 reach in the scale of health.  They never
 denaturalize the organic actions. Arsenic,
 on the contrary, never acts in the line, or,
 if continued, remains within the limits of
 healthy action.   Its  effects on the  econo-
 my  are  morbific—it entails  necessarily
disease: and  it is most probable, that its
 influence in the prevention of the inter-
 mittent paroxysm, proceeds from the wide-
 extended pathological conditions in which
 it places both the solids and fluids  of the
 economy, with the diminution of their vi-
 tal forces.  In consequence of this gene-
 ral pathological state  attended with di-
minished power, the very active but irre-
gular vital movements of concentration 
ARSENIC. (Therapeutics.)
291
 and expansion, producing a flux and reflux
 of the fluids,—a movement of congestion
 overcome  by  a recuperative  movement
 of reaction, in which consists the inter-
 mittent febrile paroxysm,—cannot be de-
 veloped.  The vital  energies  of no  one
 organ, under the depressing action of ar-
 senic, can acquire so much  of an ascend-
 ency over the vital energies of the whole
 economy as to produce this irregular com-
 motion—it  might almost be  termed in-
 surrection—in the organs of the economy.
   The practical employment of arsenic in
 intermittents  must  be  regulated  by  the
 therapeutic principles laid down. It should
 not be  administered in  cases  of persons
 predisposed to phthisis, nor in the cases
 of the grossly intemperate whose consti-
 tutions  are broken down, and  who gene-
 rally labour under chronic inflammations
 of the digestive apparatus, or in whom the
 organs  of that  apparatus  have  suffered
 from pathological vitiation of structure.
  Another  practical consideration must
 not  be  disregarded.  Chronic  inflamma-
 tions and other diseases of the viscera,
 often produce  an intermittent  febrile pa-
 roxysm, precisely resembling that of a re-
 gular intermittent.   It occurs more  fre-
 quently in individuals who have previously
 suffered  an attack of intermittent fever.
 In  them, the  disposition  to assume that
 type is so strong, that every source of dis-
 turbance to their economy is expressed by
 the  intermittent paroxysm.  The  hectic
 of phthisis bears often so strong a resem-
 blance  to common  intermittents, that I
 have known repeatedly the most experi-
 enced practitioners  who  neglected,  or
 were ignorant of, the methods of deter-
 mining by physical signs the state of the
 organs,  to be deceived, and treat for seve-
 ral months  a  case of phthisis pulmonalis
 as an intermittent.
  The far larger proportion of the cases
 usually  regarded as chronic intermittents,
 and that prove rebellious to the ordinary
 modes of treatment for that disease, are
 of the character that has been mentioned.
 The administration of arsenic in those af-
 fections  would be injudicious,  and often
 prejudicial to the patient. The  only treat-
 ment that will control cases of the kind
 must be  based on appropriate regimen,
 local depletion if the nutrition be not too
 much impaired, and  revulsives.
  Remittent fever,  it has been reported
 by Fowler, and many subsequent Eng-
 lish writers, may be  controlled by arsenic.
 But  febrile diseases with a remittent type
 are not all the same affections, and hence
the appellation  itself possesses  nothing
distinctive as a guide for the particular
forms or states to which it would be ap-
plicable.  In a climate like that of Eng-
land, moist and cold, or like that of Ger-
many, in which also arsenic has been re-
commended, fever manifesting a remittent
type may be very different from fever in
this country,  especially  in its southern
latitude.  In the United  States, arsenic is
seldom  called in aid of the practitioner,
for the management of this class of affec-
tions, and but little is known of its effects
in them from experience. While we have
means that command the confidence of
the profession and  are found adequate to
the safe treatment of our remittents, so
dubious a remedy as arsenic will not pro-
bably be enlisted.
   Cephalalgia or head-ache, when it as-
sumes a paroxysmal character is an affec-
tion in which arsenic is generally success-
ful.  Periodical  head-ache is  one of the
diseases  in which Fowler has especially
recommended arsenic,  and of which  he
reports numerous favourable results.  The
experience of Fowler has been justified
by subsequent observations.  This remedy
continues to be  resorted  to when the  af-
fection resists other means that should be
employed in the  first instance.  I  have
met with few cases in my  own practice
that have not yielded to  the employment
of the cinchonic preparations and mineral
tonics.  In some instances, head-ache can
be distinctly traced to a connexion with a
former attack of intermittent,  or to ex-
posure in  miasmatic districts  where in-
termittents  are prevalent.  It  is then to
be regarded as  a concealed intermittent
(febris larvata).   Arsenic is an effectual
remedy, as well as cinchona.   There are
also paroxysmal  head-aches  independent
of any  miasmatic  contamination, arising
from gastric disorder.  They oppress the
patient  from  severity of suffering.   In
many cases, arsenic has proved effectual
for relief, though repeated failures occur.
In these  distressing  affections, often re-
sisting  every variety of treatment this
efficient agent should not be overlooked.
   Head-ache is often persistent, but at-
tended   with  periodical  exacerbations.
Cases have occurred in the course of my
practice,  that  appeared  to  have  com-
menced in the earliest period of life.   In
one, the patient had no remembrance ofa
time when she had been free from pain in
the head, and then  was in her eighteenth
year.   She was disabled by its intensity
from the  performance of her  duties  in
life, and  debarred  the enjoyments of so-
ciety.  All treatment had proved unavafl- 
292
ARSENIC. (Therapeutics.)
ing.   Arsenic procured a marked mitiga-
tion, but, after continuing its use at inter-
vals for nearly a year, it was finally aban-
doned, the disease remaining.   In several
similar cases, the remedy proved equally
unavailing. This form of the disease, from
the only two autopsies  I have  had an op-
portunity of knowing, would appear to be
dependent on a structural change in the
arachnoid membrane with  adhesions be-
tween its free  surfaces preventing the
gentle motion of the brain in movements
of the body.
  Paroxysmal neuralgia is  found to yield
to the action of arsenic.   The neuralgic
affections—that is, disorders of sensibility,
are at this moment awakening the atten-
tion  of practitioners.  A good  history of
them is a work yet to be completed. They
often are connected with  intermittents,
follow as one of their sequelae, or appear
to proceed from the  same malarial poison
developing paroxysmal  febrile  affections.
This form of neuralgia has been noticed
by Maccolloch, who  has been  led to
generalize the fact  so  extensively,  as to
regard all neuralgic  diseases as forms of
intermittent fever.   There  are neuralgic
affections of a totally different character
and  origin.   The generalization  of Dr.
Maccolloch  is  too sweeping.   When
neuralgia assumes the complete intermit-
tent type,  attacking at regular intervals
and a fixed hour, whether it has connexion
with intermittent fever or arises  from
other causes, it is certainly controlled by
the preparations  of cinchona.   Arsenic is
equally effectual, but less  prompt in its
operation.   I have never found it neces-
sary to call  in the aid of this preparation.
The sulphate of quinia combined with sul-
phate of morphia, has in no instance that
has fallen under my observation, failed in
arresting the disease  within  forty-eight
hours.  The branches of the fifth pair of
nerves, especially the supra and infra or-
bitar branches,  have in my observations
the most frequently  manifested the symp-
toms of the affection.
   2.  Cutaneous Diseases.  Arsenic has
acquired a well-founded celebrity in the
treatment of this class of affections.  The
cutaneous diseases  to which it is adapted
are  those of the chronic character, unat-
tended with febrile  symptoms.  In all of
the  exanthemata and febrile eruptive dis-
orders, having a specific nature and pass-
ing through regular stadia, it  is useless:
it is not calculated in its mode of action
to mitigate their symptoms, and cannot
arrest their course.
   Of the numerous cutaneous affections
of a chronic  character, it  is only  in  a
small portion of them that arsenic is ad-
missible as a remedy.   In many of these
diseases, chronic inflammations of the in-
ternal  tegument exist,  as well  as of the
external tegument,  and arsenic is  very
little compatible with that state.  It may
be established as  a  general rule  for the
employment of arsenic in the chronic cu-
taneous diseases, that it can never be re-
lied  on for  producing favourable  results,
until the period of excitement often very
protracted, has terminated, and the inter-
nal surfaces are in a healthy condition.
  Of the  vesicular  inflammations, ecze-
ma,  when  chronic,  is the  only  one in
which  arsenic is  employed.   This affec-
tion, when it terminates in the production
of a moist squamous crust, is exceedingly
difficult to cure.  Arsenical preparations
are then amongst the most certain means.
They are to be used, however, with cau-
tion, and  not until  the gastric  and intes-
tinal surfaces are free from irritation. The
employment of these remedies  must also
be frequently suspended, and if signs of
internal  irritation be  present,  an emol-
lient treatment should be interposed.  It
is necessary, in many cases, to  prolong
the use of arsenic in this form of the dis-
ease, under the precautions  indicated, for
a period of several  weeks, and even for
several months.
  Of the pustular  cutaneous  affections,
chronic ecthyma,  chronic impetigo, and
porrigo, are the only forms that admit of
the arsenical treatment. These  affections,
when  they resist the  operation of other
remedies, may be successfully treated by
arsenical  preparations.   Complicated as
they are  so frequently with chronic  in-
flammation  of the  digestive apparatus, the
cautions  heretofore  laid down  must be
rigidly observed.
  In the papular  eruptions, arsenic is al-
ways injurious.  This  variety of cutane-
ous  disease  is intimately connected with
varied irritations  of the alimentary sur-
face.  It often supplants them, the exter-
nal relieving the internal disease. A trans-
lation  is easily effected, to the great disad-
vantage of the patient  I  was tempted
some years past in  an obstinate  case of
lichen agrius, of a chronic character, that
had  resisted treatment  for upwards of two
years, to venture on the administration of
Fowler's Solution.   The  affection was
translated to the  bowels, and my patient
was for some days  in danger with the
symptoms of acute enteritic inflammation.
   The tubercular cutaneous diseases, lu-
pus, cancer, elephantiasis of the  Greeks, 
ARSENIC. (Therapeutics.)
293
 difficult under the most favourable circum-
 stances  to relieve,  and often incurable,
 amongst the multiplicity of means resorted
 to, have been treated by arsenical prepa-
 rations.  The success of these remedies
 has been so very equivocal as to leave  in
 doubt the  propriety of their internal em-
 ployment  In this country, lupus is a rare
 affection, and elephantiasis graecorum un-
 known  as an original  disease.  I have
 witnessed but one case of this last.   A
 military officer  in  the  service of the re-
 public of Colombia, in some parts of which
 the disease is endemic, came  some years
 past  to  this city  for advice in his case.
 Numerous small tumours, dense, firm, in-
 sensible, embedded in the skin and cellu-
 lar tissue of the face and extremities, very
 slowly increasing in size, presented but
 few indications for the employment of any
 therapeutic remedies whose known mode
 of action could promise the eradication of
 an affection  of this  character.  All the
 means called into operation failed; he left
 this country for France, in search of re-
 lief, and when last heard of was there  in
 a deplorable  6tate,  endeavouring to pro-
 cure  a passage to his native country, but
 which he had found difficult from  the re-
 pugnance excited by the aggravated state
 of the disease.
   When arsenic is exhibited in these af-
 fections, as its  employment must  be long
 continued, it is to be given in small doses
 and but  once or twice daily.  The Asiatic
 pill containing the one-sixteenth ofa grain
 of the protoxide,  twice dady, is  usually
 preferred.
   The squamous  affections of the  skin,
 when they prove,  as they frequently do,
 rebellious to the ordinary modes of treat-
 ment may be attacked  by the arsenical
 medicines.  Willan, Bateman, Plumbe,
 Fodere, Duffin, Rush, and others, attest
 their  efficacy in relieving these affections.
 Arsenic  has, however, been often injudi-
 ciously prescribed  in the  squamous  dis-
 eases, and  injurious effects have resulted
 from  them.  In the early  and inflamma-
 tory  stages,  arsenic  is  inapplicable:  it
 generally fails.  It is more frequently suc-
 cessful in cases that have become chronic
 and have continued a long period. Neither
 should it be  brought into operation until
 after depletory means, emollient baths, and
 a suitable  regimen, have been in opera-
 tion.   When  these  fail  to  accomplish  a
 cure,  they prepare the way for the suc-
cessful co-operation of arsenic.  It must
not be overlooked that in these affections
the digestive apparatus is often deeply in-
 volved, and irritations of considerable in-
                 25*
 tensity exist   Arsenic is then injurious,
 from the aggravation of those affections,
 and is utterly unavailing in  relieving the
 cutaneous disorder.  I have treated a num-
 ber of cases of lepra vulgaris and psoria-
 sis, modifications of the same form of dis-
 ease.   In one that had continued  for sev-
 enteen years,  from  childhood, the  most
 complete relief was procured by the  com-
 bined operation of bleeding,  regimen, and
 emollient baths, followed up for several
 months, and finally assisted  by Fowler's
 solution continued for eight weeks.  In
 this case, the digestive  apparatus mani-
 fested a perfect integrity of  functions.  In
 another case of eight years' duration, a
 similar treatment was equally successful
 after a treatment  of two months.  At this
 time there is under my charge a lady who
 has been affected four  years with  this
 eruption; but in her case such is the irri-
 table condition  of the stomach that a sin-
 gle drop  of Fowler's solution cannot be
 taken.  In lepra and psoriasis, it will  most
 probably be found,  that arsenic is not
 adapted to the  treatment of the first pe-
 riods. The emollients, temperants, deple-
 tives, baths, with the milder alteratives,
 are to be preferred.  In many cases I  have
 found that method the most available.  But
 in  ancient cases, when the local and  con-
 stitutional irritations have subsided or are
 worn out then arsenic will often prove
 an  effectual cure.
  In the eruptive and ulcerative affections
 of  the internal teguments, the experience
 of  the  effects of arsenic is too limited to
 build  on it any  therapeutic  directions.
 This class of diseases is yet too  little
 known to justify positive methods of treat-
 ment  They are probably  as numerous
 and as varied  as those that  are observed
 on  their congenerous structure, the exter-
 nal tegument   The  different  sensibility,
 irritability, and important functions of the
 internal surfaces,  modify very materially
 the symptoms and results of  affections de-
 veloped in them analogous to those of the
 skin.  The same circumstances  modify
 also the  effects of remedies, and render
 those inadmissible in the one that may be
 perfectly adapted  to  the other.   In  the
 larger number of these affections, arsenic
 possesses powers too active, and influences
 too immediately the suffering surface, to
 be safely employed.  The extent of what
 is known in this respect is, that in chronic
 ulcerations of the fauces and pharynx, un-
 attended with febrile symptoms and  gas-
 tric irritations, Fowler's Solution applied
as a lotion, and internally administered,
has often  proved the  most successful re- 
294
ARSENIC.  (Pharm. and Posol.)
medy after other means had been unavail-
ingly employed.
  3. Syphiloid Affections.  Various erup-
tions, tubercles,  and ulcers,  appearing on
the skin,  osteocope pains, nodes on  the
bones,  have often a character resembling
affections  formerly attributed to syphilitic
virus. Their origin appears doubtful. This
is not  the place to discuss  the question.
In these affections,  arsenical preparations
are often  successful even after a mercu-
rial course has failed.  Professor Physick
has found the arsenical remedies,  alter-
nated with short and light courses of mer-
cury, a very  effectual treatment in this
form of disease.
   4. External Application.  At one time,
the arsenical  preparations were very ex-
tensively  resorted to as external applica-
tions, but the  serious consequences which
frequently followed their  employment in
this mode (see pp. 285-6.) have much re-
stricted their  use.  With proper precau-
tions they may, nevertheless, be resorted
to in certain cases,  with great advantage.
   The  employment of the  arsenical pre-
parations  in cancerous and some other in-
tractable affections, is sustained by a strong
mass of facts derived  from experience.
The empirics  who profess to cure cancers,
and whose treatment is occasionally suc-
cessful, in very bad ulcers, most commonly
use  arsenic disguised in some shape.  As
a general  rule, the knife is to be preferred
where  extirpation  can  be  accomplished.
But there are cases  in which this  is not
possible;  and in others, where consider-
able mutilation would be required, a local
treatment should in the first instance be
attempted.  Cancerous ulcers of the lips,
of the nose  and face, are often brought to
heal by the  use  of arsenic.   The powder
of Dupuytren has been  repeatedly suc-
cessful in these cases.  In two cases,  one
of the lip, and another  of the nose, I ob-
tained a perfect success.  It does not ap-
pear to act as a caustic, but rather as a
very  powerful alterative  of the  organic
actions of the part  Before applying it,
the surface  of the sore must be rendered
clean by  poultices.   Many  years past, I
witnessed a successful treatment ofa case
of fungus hematodes (not Heys, which is
the medullary fongus,)  on  the wrist by
Dr. Physick.   The arm was confined in
splints, and arsenic freely applied.   The
recovery was complete.   Another, of me-
dullary fungus on the arm, was success-
fully treated at Germantown, on the same
plan.  The  patient  has remained well for
four years.  It has been remarked that in
cancerous affections, the local application
of arsenic is not liable to produce consti-
tutional symptoms.  It does not appear to
be  absorbed from  a  cancerous surface.
Some years since, the arsenical treatment
procured a prolongation of life in a case
that fell under my charge.  The breast
had been removed with the glands in the
axilla, for a cancerous disease.   Several
tumours subsequently formed.  They were
hard at first, semitransparent, and straw-
coloured.   As they advanced,  they  be-
came very vascular and of a bright scar-
let.  After some weeks, they would bleed.
Various treatment  was resorted to,  and
finally settled  down to the application of
Rousselot's arsenical paste.   The tu-
mours would slough off and be reproduced
without extension of the base, at the end
of three or four weeks. This plan was con-
tinued for three years.  When I last heard,
her general health remained unaffected.
  As a means for arresting the progress
of certain carcinomatous  ulcers, and to
change the  mode of action of some chro-
nic ulcers, arsenical preparations are some-
times employed with success. MM. Biett
and Cazenave have obtained advantages
from their application, in  the  cure  of lu-
pus (Diet, de Mid.  IV. 31.), and Dr. Ran-
dolph  has  been  equally  successful with
them in a case of peculiar ulcer of the scro-
tum.  (N. A. Med. and Surg. J. V. 257.)
                          S. Jackson.
   5  4.  Pharmacy  and Posology.   The
preparations of arsenic, or those into which
this substance enters  as the chief ingre-
dient which have been employed in  me-
dicine, are exceedingly  numerous;  and
although the greater number of  them are
now rarely, if ever, used, still it may be
reasonably  expected, in a work like the
present, that those, at least, which have
enjoyed most celebrity,   should not be
passed over without some  notice.
   Sulphurets of Arsenic.   These  are
rarely used in medicine.   Hecker, how-
ever, boasts of the  efficacy of the follow-
ing  powder in intermittent fever:  Take
of the sesquisulphuret of arsenic, half a
grain; white sugar, half a  scruple; oil
of aniseed,  one drop.   This is  to be di-
vided into twelve doses,*of which one is
given every hour during the apyrexia.
   Orpiment also  enters into the composi-
tion of the Green Balsam of Metz, of Lan-
franc's Collyrium, and of many depila-
tories.
   Arsenious Acid.   This is employed in
a variety of forms, both as an internal re-
medy and as an external application. The
dose when administered internally is from
one-twelfth  to one-eighth of a grain. 
ARSENIC.  (Pharm. and Posol.)
295
   The Solution of Lefebure, for the cure
 of cancer, consisted of arsenious acid, two
 grains; rhubarb, half an ounce; syrup
 of chicory,  q. s.; distilled water,  a pint.
 Of this mixture, a table-spoonful was given
 every night and morning, with  a fluid
 drachm  of  the syrup of poppies.  Each
 dose contained about a twelfth of a grain
 of the acid.  The dose was gradually in-
 creased to six table-spoonsful. ( U. S. Dis.)
   Asiatic Pills.   Take of arsenious acid,
 sixteen  grains; powdered black pepper,
 two and a half drachms; mucilage of gum
 Arabic,  q. s. The arsenious acid and pep-
 per are to be long triturated together in a
 mortar, and the mucilage then added. The
 mass is to be divided into two hundred
 pills, each  of which contains about one-
 thirteenth ofa grain of the arsenious acid.
 The dose is one pill daily, and must  not
 exceed two during the same period.
   Barton's Pills.   Take of arsenious
 acid, two grains; powdered opium, eight
 grains; soap, twenty-two grains.   Make
 thirty-two pills, each  of which will con-
 tain one-sixteenth of a grain of the acid.
 The dose for an adult is  two  or three  of
 these pills daily.
   Plenciz's Powder.  Take of white ar-
 senic, myrrh, long pepper, and Armenian
 bole, each  two grains;  flowers of sul-
 phur, half an ounce; antimonic acid, one
 drachm.  Mix and  pulverize very finely.
 The dose is six or eight grains in chamo-
 mile tea, which  is given an hour or two
 before the paroxysm of intermittent fever.
   Fontaneille's Powder for the cure of
 intermittent fever. Take of white arsenic,
 two grains; calomel, sixteen grains; opi-
 um, two grains; gum Arabic, and sugar,
 of each  one drachm.  Mix together and
 divide into  sixteen doses.
   Arsenious acid is a powerful caustic,
 and it constitutes the basis of the powders
 and pastes employed as escharotics.  These
 pastes are made by mixing with saliva or
 water, or gum-water,  the arsenious acid
 or some one of the arsenical powders,  as
 that of Rousselot.  This mixture should
 be made on  a tile, with a spatula, and  the
 soft paste thus made  is  to be uniformly
 spread with  the instrument just mentioned
 over  the surface to  be cauterized.  The
 layer of  paste should never exceed a line
 or a  line and a half in thickness.  Care
 should also be taken to confine the caustic
 to the parts  intended to be destroyed. The
application of this paste occasions a burn-
ing pain, and often local  symptoms  of an
apparently alarming character; such as
erysipelas, with much redness  and  tume-
faction, especially when  the  remedy  is
 used to the  face.  These soon disappear,
 or readily yield  to emollient and cooling
 drinks, pediluvia, a few leeches, or at most
 a small bleeding.  A black, very  thick,
 and firmly adherent eschar forms,  which
 does not separate  for  a long time, often
 twenty or thirty days,  or longer.   Some-
 times when  it  drops  off, the  cauterized
 part is covered with a more or less solid
 cicatrix.
   Before applying the  arsenical paste, the
 parts to be  cauterized must be  properly
 prepared.  Thus, if there  exist on them
 any crusts or vegetations, the former must
 be removed  by  emollient  poultices; the
 latter must be excised, and the wound co-
 vered with agaric or lint and three or four
 days suffered to elapse, till these foreign
 bodies are cast off.  Sometimes it is  use-
 ful  to excite the  surfaces by a blister,
 which is to  be  removed immediately be-
 fore the cauterization is to be made. This
 precaution, M. Cazenave says,  is often in-
 dispensable in the treatment of lupus, es-
 pecially that form  of it  which M.  Biett
 has denominated lupus with hypertrophy.
   With prudence and care in using these
 pastes, the untoward accidents which have
 resulted from their employment and of
 which so many  examples are  recorded,
 may be probably always avoided.   Saba-
 tier, Dubois, Dupuytren,  and Physick,
 who have so  frequently made use of them,
 have never witnessed any alarming conse-
 quences from their use; and  Cazenave
 says that he has often seen  them applied
 and used them himself, with like good for-
 tune. They are unquestionably, however,
 very active medicaments,  and their use
 requires the  closest attention and utmost
 prudence.
   Rousselot's  Arsenical  Paste for the
 cure of cancer,  is prepared, according to
 the French Codex,  of two parts of arseni-
 ous acid, and of sixteen parts each, of cin-
 nabar and dragon's  blood.  Cullerier at-
 tributes to the dragon's blood the property
 of preventing the  absorption  of the ar-
 senic.
   The  powder  of  frere Cdsme  (Pulvis
 Cosmii sive  Bernhardit) seems to have
 differed from that  of Rousselot in  the
 proportions only of  the ingredients.   The
 formula? for these preparations, as  given
 by different authors, differ much.
   Pomade of Hellmcnd, for the cure of
 cancers of the face. Take of cinnabar,
 half a drachm; of the cinders of old sole
 leather,  and  dragon's  blood, each four
grains; of white arsenic, twelve grains
(according to  some formulae,  ten grains).
Make a powder, and incorporate a grain 
296                     ARSENIC.  (Pharm. and Posol.)
and  a half of this with a drachm of the
following ointment:—Take of balsam  of
Peru, extract of cicuta, each one drachm;
of acetate of lead, one scruple;  of lauda-
num, ten  grains; of simple cerate,  two
ounces.  This  pomade  at one  time  ac-
quired such celebrity, that the  secret of
its  composition was purchased by  the
Prussian government: it is a clumsy imi-
tation of the Paste of Frere Cosme,  and
of the old anticancerous  remedy of Da-
vidson.  It is no longer in use.
  Arsenical Pomade. Take of white wax,
two drachms; of butter, six drachms; of
white arsenic, four grains.   Mix.
  Arsenical  Cerate.  Take of  arsenious
acid  in very  fine powder,  a  scruple; of
simple cerate,  an ounce.  Mix the acid
with the cerate previously softened by heat.
  Swediaur's Arsenical Liniment.  Take
of arsenious acid, from one to two grains;
oil of olives, one ounce.
  Swediaur's Anticancerous Cataplasm.
Take  of white  arsenic,  half an ounce;
camphor, one ounce; vinegar,  one pint;
juice of carots, two  pints; powdered  ci-
cuta, q. s.   Mix.
  Plunket's Caustic.   Take of the  Ra-
nunculis acris and Ranunculis ffammula,
each  an ounce, bruise  and  mix with a
drachm of arsenious acid and five scruples
of sulphur.   Beat the whole into a paste,
form into balls, and dry in the sun.  When
used, it is to be rubbed up with the yolk
of egg, and spread upon  a piece of blad-
der.  (U. S. Disp.)
  Dupuytren's Powder  is a mixture of
the protochloruret of mercury and arseni-
ous acid, in the proportion of two hundred
parts of the former,  to one or two of the
latter.  It  is said to be a  mild  and often
very useful caustic,  and  to be  especially
applicable to  children and irritable indivi-
duals. It is  dusted  on the part we wish
to cauterize.   Most  frequently  it  causes
no pain; nevertheless, it is prudent not to
apply it to too large a surface  at a time.
A grayish very  adherent  crust is soon
formed, which does not separate for a long
time, unless this is promoted by  emollient
applications.   Ordinarily, it is  necessary
to apply the  powder several times before
a good cicatrix is obtained.
  Dr. Hugh  Martin's  Cancer  Powder,
described  by  Dr. Rush  (Trans.  Amer.
Philos. Soc.  II. 212.), consisted  of arseni-
ous acid and vegetable matter; in the pro-
portion of one part of the former to forty
of the latter.  In the specimen experi-
mented on by  Dr. Rush, the  vegetable
matter was belladonna.  This powder sel-
dom produced an eschar, but only mode-
rate inflammation.   Dr. Rush, who wit-
nessed its application, bears testimony to
its  having performed complete cures in
several cancerous ulcers, mostly seated on
the nose or cheeks, or upon the surface or
extremities of the body;  but  where the
disease was  connected  with a scrofulous
diathesis, it always failed, and in some in-
stances did evident mischief.
   Arsenical  Ethiops,  recommended  by
Adair for the  cure of yaws and  some
other obstinate  diseases  of the  skin, is
prepared  by  well triturating together one
part of white arsenic with three parts of
sulphur.  (Duncan. Med. Comm. for 1785.)
   Lefebure's Cancer Wash consisted of
ten grains of arsenious  acid dissolved in a
pint of distilled water, to which were add-
ed  an ounce of extractum conii,  three
fluidounces of liquor Plumbi subacetatis,
and a fluidounce of laudanum.  With this
the  cancer was washed  every morning.
(U.  S. Disp.)
   Ioduret of Arsenic.  This has been em-
ployed in the form of  ointment only, for
which the following is the ordinary for-
mula: Take of ioduret  of arsenic, one
part; lard, eighteen parts.  Mix.
   Arsenite  of  Potassa.    This   salt is
never used pure.  Dissolved in water, it
forms Fowler's Solution.  The formula
for the preparation of this,  as given in the
U. S. Pharmacopoeia, is as  follows:  Take
of  arsenious acid  in  very fine powder,
purest carbonate of potassa, each, sixty-
four grains; distilled water, a sufficient
quantity;  compound spirit  of lavender,
four fluidrachms. Boil  the arsenious acid
and carbonate of potassa  with a pint of
distUled water, till the acid is entirely dis-
solved.   To  the  solution, when cold, add
the spirit of lavender, and  afterwards suf-
ficient distilled water to make it  fill up
exactly the measure of a pint.   As ob-
served by Dr. Bache ( U. S. Disp. p. 795.),
to form a  perfect arsenite of potassa,  theo-
ry would call for 50 of acid and 70 of the
carbonate, instead of equal parts;  so that
the quantity directed of the latter is defi-
cient  Each fluidrachm of the solution
contains half a grain of the  arsenious  acid.
Fowler  administered this preparation in
the dose  of from ten to twelve drops two
or three  times a day.  In this dose  it is
apt to disorder the digestive organs.  In
intermittent fevers we have found  five or
six  drops three  times a day to be gene-
rally sufficiently large doses.  In diseases
of the skin, where  it is to be long  con-
tinued, we prefer commencing with smaller
doses, as three or four drops two or three
times a  day, and  gradually increasing 
ARSENIC.  (Bibliography.)
297
 them  to  six  or seven drops  during  the
 same  period.   Few persons  can  support
 larger doses for any great length  of time
 without experiencing gastro-intestinal ir-
 ritation  or irritation of the  lungs.  Mr.
 Ireland states that he has given it in the
 enormous dose  of two drachms, with con-
 stant success, for remedying the effects of
 the bites of poisonous serpents.  An imi-
 tation of this practice cannot be safely re-
 commended.   In  all cases, the employ-
 ment of this active medicament should be
 closely watched, and the dose diminished
 whenever signs of gastric or intestinal ir-
 ritation  appear;  and  in  chronic  cases,
 where  it is necessary to continue the re-
 medy for a considerable period, it is most
 prudent occasionally to intermit its use for
 some days.
   Arseniate of Soda.  This is the base
 of the arsenical solution of Pearson and
 of that of Heincke.
   Pearson's Solution consists of one grain
 of the arseniate of soda dissolved in one
 ounce of distilled water. This liquor con-
 tains  one-eighth of a grain of the salt to
 each drachm, and the dose is half a drachm
 daily.  In irritable persons, and especially
 females, it is best to give  this  quantity in
 two doses, or one-fourth of a drachm morn-
 ing and  evening.   Pearson  gave  it  in
 doses of from  sixty to one  hundred and
 twenty drops,  in intermittent  fevers and
 cutaneous diseases.  It is  less  dangerous
 and less active  than Fowler's Solution.
   Solution of Heincke.   Take of arseni-
 ate  of soda, six grains;  mint-water, two
 ounces and a half; vinous tincture of cin-
 namon, one ounce and a half; laudanum,
 one drachm.   The dose  is forty or fifty
 drops four times a day.
   Arseniate of Iron.   Take of the prot-
 arseniate of iron, three grains; extract of
 hops, two drachms; powdered marsh mal-
 low,  half a drachm; syrup, q. s.   Make
 forty-eight pills. This is recommended by
 some English writers for the cure of can-
 cerous affections and herpetic ulcerations.
 The dose is one pill daily.

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richtlicher Hinsicht.  Vienna, 1820.  8vo.
  Prescot.  Case of protracted Syphilis [cured
by Arsenic];  in New  England Joum. of  Med.
and Surg.  X. 228.  Boston, 1821—Ibid. Obs. in
same Journal.  X. 341.
  Kittridge, (R.)   On  the effects of Fowler's
Mineral Solution in controlling Spasm; in  same
Journal.  X.  345.
  Christison.  An account of several cases of
poisoning with Arsenic, in  illustration of the deli-
cacy of the chemical evidence, and the weight of
the evidence drawn from the symptoms; in Trans.
of Med. Chirurg. Soc. of Edinb. II. 273. (1826.)
  Dewees.  Case of intermittent in a child of six
weeks of age, cured by Arsenic; in Philada. Joum.
of Med. and  Phys. Sc.   XIV. 187.  (1827.)
  Alexander, (J.  M.)   Case  of a  very  painful
and protracted head-ache cured by Arsenic;  in N.
A. Med. and Surg.  J. IV. 290.  philada. 1827.
  Otto, (J. C.)  Case of chronic head-ache suc-
cessfully treated with Fowler's Arsenical  Solu-
tion ; in same Journal.   V. 268.  (1828.)
  Coxe, (D. T.) Remarks on the remedial  value
of Arsenic; in same Journal.   VIII. 41.  (1829.)
  Christison.  Account of the medical evidence
in the case of Mrs.  Smith tried for murder by poi-
son ; with notes and commentaries; in Edinburgh
Med. and Surg. Joum.   XXVII.  441.  (1827.)
  Mackintosh's  Reply to the above  criticisms;
in same Joum.  XXVIII.  84.
  Christison.  Obs. on the duration of Cholera,
the taste of Arsenic, and its power  of preserving
from decay the bodies of those poisoned  with it;
being an answer to Dr. Mackintosh's Reply; in
same Journ.  XXVIII. 94.
  Gairdner. Case of poisoning by  Arsenic, with
Obs.; in same Journal.  XXXII. 305.  (1829.)
  Forbes.   On a new mode of employing the ni-
trate of silver as a test of Arsenic; in same Journ.
XXXII. 335.
  Ward.   A case  of poisoning by Arsenic, with
Obs. by Dr. Christison ; in same journ. XXXIII.
61.  (1820.)
  Christison.  Case of poisoning with Arsenic;
in same Joum.  XXXIII.  67.
  Meriwether.   Two  cases of poisoning; in
Transylvania Journal of Med.   II-   233.  Lex-
ington, 1829.
  Henderson, (John.)  Case of disease of the
bones successfully treated by tlie internal exhibi-
tion of Arsenic; in American Joum. Med. Sc. V.
58.  Philada. 1829.
  Devergie and Rayer.  Art Arsenic, in Diet de
Med. et de Chirurg. Prat.   III. 324.   Paris, 1829.
  Marx.  Die Lehre von den Giften.
  Merat et De Lens.  Arts. Arsenic et Arseni-
caux, in Diet de Mat Med.  I.   Paris, 1829.
  Dunnel.   Case of recovery  from poisoning
with a large dose of Arsenic; in New-York Med.
and Phys. Joum. N. S.  II. 114. (1830.)   In this
case, at least an ounce and a half of white oxide
of arsenic was supposed  to have been taken.
  Ward.   Case of poisoning by Arsenic.  Edin-
burgh Med. and Surg. Joum. XXXIII. 61. (1830.)
  Venables, (Robert.) Observations critical and
explanatory on some of the most approved methods
for the detection of arsenic and its compounds in
anitnalized fluids;  in London Med. Gazette. VI
615.  (1830.)—Ibid.  Farther Observations, in same
Journ. VIII. 804. (1831.), and in  American Journ.
Med. Sc. IX. 525.  Philada. 1832.—Ibid.  Effects
of Arsenic upon poultry,  with the morbid appear-
ances in the viscera;  and on the  relative value of
the various modes of Analysis devised and investi-
  fated by Dr. Christison ; in same Journal.  X
  15.   (1832.)
  Jennings, (Egerton A.) Poisoning by Arsenic
and Laudanum combined, in which the symptoms
usually produced by Arsenic were absent; in Lon-
don Med. and Phys. Joum. N S. IX.  295. (1831.)
  Worthington.  A case of poisoning with ar-
senious acid, which was  detected in  the  stomach
after death; in North American Med. and Surg.
Joum.  X. 229.  Philada. 1831.
  Kerr, (Wm.)  Case where a large  quantity of
Arsenic was entirely expelled from "the stomach by
Emetics two hours after it had been swallowed; in
Edinb. Med. and Surg. J.  XXXVI. 94.   (1831.)
  Christison.  A Treatise on  Poisons, in rela-
tion  to Medical Jurisprudence,  Physiology, and
the Practice of Physic. 2d edit  Edinburgh, 1832.
  Mitchell, (J. Iv.)   Observations on Arsenic;
in American Journal Med. Sc.   X. 121.   (1832.)
  Gould, (A. A.)  Observations on poisoning by
Arsenic, with two cases; in Medical Magazine.  I
273.   Boston, 1832.
  Perrine.  Case in which a very large dote of
Arsenic mxzs taken by mistake, without fatal conse-
quences;  in Am. Journ. Med. Sc. XI. 61. (1832.)
  Mitchell and Durand. On Arsenic;  in Jour-
nal of Philada. College of Pharmacy. July, 1832.
IV.  108.
  Orfila, Soubeiran, and Cazenave.  Art Ar-
senic, in Diet. de. Med.   IV. 1.   Paris, 1833.
  Thwaites.  Obs. on the use of Arsenic in  cu-
taneous diseases; in  Edinburgh Med. and Surg.
Joum.  XLII. 334.  (1834.)
  Murray, (A.)   Observations upon Arsenic; in
Edinb. Med. and Surg. Joum. XLI.  365. (1834.)
  Ramsay, (W. G.)  Twelve Cases of Poisoning
in the same family.   American Joum. Med. Sc.
XV. 259.   Philada. 1834.
  Bunsen und Berthold. Das Eisenoxyhydrat,
ein Gegengift  der arsenigen Saure.   Giittengen,
1834.  8vo.
  Rogers, Andrews, and Fisher.   Minutes of
an analysis of soup containing Arsenic; in Joum.
of Philada. Coll. of Pharm. VI. 94.   July, 1834.
  Caunce.  Toxicological considerations on Ar-
senic and ils compounds; in Journ.  of Philada.
College of Pharmacy.  Oct 1834.  VI. 190.
  Bouley, (Je,une.)  Experiences constatant Veffl- 
ARTEMISIA.
299
caciU de Vhydrate de piroxide de fer comme anti-
dole de Varsenic. Mem. lu a l'Acad. Roy. de Med.,
le 4 Mare, 1834. In Gaz. Med. 7 Mare, 1835.
  Symonds, (J. A.)  Some remarks on the Bristol
case of Poisoning, and on Disinterment for Fo-
rensic purposes; in Trans. Provincial Med. and
Surg. Association.  III.  432.  London, 1835.
  Tacfflier.   Procidi analytique pour dicou-
vrir les priparations arsenicales en dissolution
awe des matiires organiques; in Joum. de Phar-
nmcie.  XX.   392.  Paris, July, 1834.;  and in
American Joum. of Pharm. VII. 71.  April, 1835.
  Boxelli and Deharia.  Experiments on the
employment of the hydrate of the tritoxide of iron
as an antidote to Arsenic; in Repertorio Medicc-
Chirurgico del  Piemonte.  A summary of these
experiments, the results of which are favourable
to the efficacy of the  antidote, is given in La
I.ancette Francaise, 19 May, 1835.
  Tyson and Fisher.  Minutes of the analysis
of Bread, which had caused the severe illness of
four persons, and death of two, in Frederick Co.,
Md.;  in American Journal of Pharmacy.  VII.
107. July, 1835.
  Beck, (T. R. and J. B.)  Elements of Medical
Jurisprudence.  5th edit. II. 330.  Albany, 1835.
  See also the general treatises on Toxicology
and Medical Jurisprudence, particularly those of
Ducatel, Cooper, Fodere, Orfila, and Ryan.
                             I. Hays.
  ARTEMISIA. (Botany and Mat. Med.)
  Sex. Syst.  Syngenesia superflua.  Nat.
Ord.  Compositeae.
  Gen. Ch.   Involucre imbricate. Scales
round, connivent. Florets of the ray none.
Pappus none. Receptacle naked, or slight-
ly villous. Beck.
  All the plants  of  this genus  are bitter,
aromatic, and possessed  of medical  pro-
perties.   The genus is very extensive, be-
ing composed of  upwards of one hundred
species, all of which  are found in the most
sterile spots.  None of them  are recog-
nized by the U. S. Pharmacopoeia, and but
few by those of Europe.  These are
  1.  A. absinthium.  Wormwood.   Ab-
sinthe, Fr.;  Wermuth, Germ.
  Sp. Ch.   Stem  branching,  panicled;
leaves hoary; radical ones triply pinnati-
fid; divisions lanceolate, toothed, obtuse;
cauline ones two-pinnatifid, or pinnatifid ;
divisions  lanceolate, acutish; floral ones
undivided, lanceolate.   This species  is a
native of Europe, where  it is  also culti-
vated for medical purposes.  It appears to
be naturalized in most of the mountainous
parts  of  New England  (Eaton), and  is
very common in gardens. It has a strong,
penetrating smell, and an extremely bitter
and aromatic taste,  which  it imparts to
water and alcohol.   It owes its properties
to a dark-green volatile oil.  Its medical
properties are those of a stimulant  and
tonic, and it  is much employed as a sto-
machic in the form  of tincture.  Before
the  introduction of Peruvian bark, it was
a favourite febrifuge in intermittent  fe-
vers.  As an emmenagogue it is of little
value, though enjoying a high reputation
as such, in domestic practice.   It is also,
like many of the other bitter herbs, much
employed  as  an anthelmintic.  It is an
energetic stimulant,  and should never be
administered where any irritation  of the
stomach exists.
  It is given in a variety of forms: 1. In-
fusion made with one ounce of the herb
to a quart of water; 2. in powder, dose
one  to  two scruples; 3. vinous tincture,
dose  half an  ounce  and upwards.   The
principal preparation, however,  is the al-
coholic tincture or Eau d'absinthe,  which
is much used in Europe, to excite the ap-
petite.
  2. A. vulgaris. Mugwort.  Armoise, Fr.
  Sp. Ch.   Leaves downy beneath; cau-
line  ones  pinnatifid;  divisions lanceolate,
sub-toothed, acute; floral ones undivided,
linear lanceolate; flowers  sub-sessjle,  ob-
long, erect;  calyx hairy.  This  is  ex-
tremely common in  Europe,  and is also
found in  Canada and the New England
States, on the banks of streams.  It has
somewhat the odour and taste of  worm-
wood, but is less energetic  in its  action
on the  system.   It is most generally em-
ployed  as an emmenagogue,  though its
powers are but feeble and only suited to
those cases where a slight stimulus is re-
quired.   Some German  writers have as-
serted that it has proved eminently useful
in epilepsy, and many cases  are reported
in the foreign Journals in  support of this
opinion. Dr. Burdach, who experimented
largely with it, advises the following mode
of administration:  A dose of half a drachm
of the powdered  root is to be given, when
the patient begins  to experience the pre-
cursory symptoms,  and he is to retire to
bed to encourage perspiration.  The sec-
ond  dose  is two  scruples.  This is gene-
rally sufficient to arrest the paroxysm ; if
not,  the succeeding  doses are to  be in-
creased to a drachm  or a drachm and a
half.  (Archives Gin. de Mid. VII.  588.)
  Many other species of Artemisia have
been employed for  medical purposes. The
A. abrotanum, or southernwood of the gar-
dens, was at one time in high repute as
an alterative  and  anthelmintic.  The A.
dracunculus, or Tarragon, is in general use
as a condiment, but has not been employed
for medical purposes. Several of the Asiatic
species afford an anthelmintic much esteem-
ed in Europe under the name of Semen con-
tra (q. v.). The Chinese Moxa (vide Moxa)
is prepared from plants of this genus.   Fi-
nally, under the name of Genipi the Alpine
species  are in general repute in Switzer-
land as vulneraries  and 6udorifics.
                      R. E. Griffith. 
300                         ARTERY. (Gen. Anat.)
  ARTERY.  (From o/no, air, and trjpsw,
to retain  or  protect, because  this term
was at first only applied by the ancients,
to the trachea,  opr^pto tpa^tio, arteria
aspera, and was not used in its present
acceptation, until  Erasistratus, proba-
bly from  seeing  the arteries empty after
death,  supposed  they conveyed air from
the heart and lungs, to all  parts of the
body,  and applied the appellation to them
which  they have since borne.)  o^tf^ta,
Gr.; Arteria, Lat.; Artere, Fr.
  The arteries  are elastic  tubes, which
convey the blood from the right and  left
ventricles of the heart,  to every part of
the body.
  Art. I.  General Anatomy of the  Ar-
teries.   Examined  in their totality,  the
arteries consist of two great trunks, which
present an arborescent  arrangement, the
root of each being the base of one of the
ventricles, while the numberless ramifica-
tions formed by its successive divisions
and subdivisions, are spread out in  the
substance of the various organs to which
the blood is circulated.  The first of these
trunks is the pulmonary artery, which,
proceeding from  the base of the right ven-
tricle, sends its  ramifications exclusively
to the lungs, where they commimicate
with the  radicles of the pulmonary veins,
which  return the blood  to the heart after
it has undergone the changes  impressed
upon it by respiration.   These parts form
what is called the lesser or pulmonary cir-
culation.   The second is the aorta, which
proceeds  in a similar manner from the left
ventricle, but distributes its ramifications
to every  part of the body,  where they
communicate with   the  radicles of  the
veins, which return the  blood to the right
side of the heart. It forms, therefore, the
trunk of  the greater, or systemic circula-
tion.
  § 1.  Type  and distribution of the arte-
ries. The type of the arterial system may
be compared to a tree, the trunk of which
is  rooted in the base of the ventricle of
the heart, while its numerous  ramifica-
tions branch into the substance  of the va-
rious organs.  The trunk, as well as the
branches and  ramifications,  are for  the
most part perfectly cylindrical.  But as
the arteries divide  and  subdivide in their
progress,  the  cylinders  are perpetually
growing smaller, as the arteries advance
from the heart towards the periphery of
the organization. Thus each artery, traced
from its  origin  to its termination, repre-
sents a succession  of tubes, or cylinders,
of unequal size, terminating in each other,
and becoming progressively  smaller  the
further they are removed from the heart.
A vessel  examined  in this manner, will
represent a hollow cone, with its base di-
rected towards the heart; but if attention
be paid to its  different segments,  or the
space between its several divisions, it will
be found  that  they are cylindrical, and
that the conical arrangement merely de-
pends  upon  each division or bifurcation
representing a smaller  sphere than the
trunk or branch which precedes it.
  But while each artery, viewed in this
manner, resembles a cone, with its base
corresponding to the centre of the circu-
lation, if the aggregate capacity of all the
ramifications be  compared with that of
the aorta from which they proceed,  it will
be found that the former  transcends the
latter so far, that when the entire capacity
is taken collectively, it will represent an
inverted cone, having its summit directed
to the heart, and its base forming the peri-
pheral portion of  the vascular system.
  The order in which the arteries  divide
and subdivide,  as they advance from the
centre towards the circumference  of the
body, is subject to several varieties in dif-
ferent situations, but is everywhere radi-
ated.    Sometimes  an  arterial  trunk or
branch divides  into two branches of nearly
equal magnitude, as in the common caro-
tid, the division  of the abdominal aorta
into  the primitive iliacs,  and the latter
into the external  iliacs.  More frequently,
however,  the branch continues to  distri-
bute ramifications in  its course, until it
is entirely  expended.  The  number  of
branches  given off by any artery  is sub-
ject  to  considerable variation.   Haller
and  Meckel have estimated twenty as
the maximum, under ordinary  circum-
stances  ; but some  anatomists have rated
the number as high  as forty  or  more.
There are but few arteries which send off
twenty branches between their origin and
termination,  and  with a few exceptions,
from ten  to  thirteen or fourteen may be
regarded as the maximum.  The internal
maxillary and the ophthalmic may be taken
as examples, each  of  which usually fur-
nishes about thirteen branches.
  The  angle of bifurcation presents con-
siderable  differences,  and  cannot  be re-
ferred to any fixed law.  It was long since
observed by  Hunter,  that those arteries
which take their origin nearest the heart,
generally come off" at  right angles, in or-
der that the impulse  of the blood  which
is strongest there, may be partially  enfee-
bled or decomposed.   This disposition is
observed  in  the  origin of the  branches.
from the  arch of the aorta, the  lower 
                           ARTERIES.

intercostals,  the  phrenic,  cceliac,  and
emulgent arteries.   Some even separate
at obtuse angles, as, for example, the two
coronaries, the superior  intercostals, and
the recurrent branches of the extremities.
More generally, the angle  of bifurcation
is more or less acute, the degree of the
angle varying very much, however, in the
different arteries.   Haller represented
that the measurement, under ordinary cir-
cumstances, presents an approximation to
45°; but to this there are  numerous ex-
ceptions; since many of them, as the  sper-
matics, the carotids, and the arteries of
the  extremities, generally separate at an-
gles which are exceedingly acute.
   The diameter of many arteries is slight-
ly increased  at the  point at which  they
are  about  to  divide.  This is  especially
manifest at the bifurcation of the common
carotid.  It was doubtless this  dilatation,
that induced Hunter to represent the ar-
teries as conical, the expanded extremity
of the cone being furthest removed  from
the  heart.  The  internal  aspect of the
vessel also presents some difference, ac-
cording as the bifurcation  forms an ob-
tuse,  a right,  or  an acute angle.  In the
first case, there is an acute margin or pro-
jection corresponding to the point of sepa-
ration, haying its edge directed from the
heart, and  projecting more or less into the
lumen of the  artery.  When the division
takes  place at a right  angle, a similar
margin occupies the whole contour of the
branch which is given off; but when the
direction  of tbe bifurcation is acute, the
prominent angular border, or spur, has its
edge directed  towards the heart, and is so
disposed as to exercise considerable influ-
ence in dividing the current of blood into
two streamlets when it impinges against it.
   The arteries range for the most part in
right lines, and many of them run parallel
with the axis of the trunk, or the extremi-
ties, through which they take their course.
Nevertheless,  many exceptions  to this
rule are observed in the large trunks,  as
well as in the branches and smaller rami-
fications.  Thus the aorta, even in the im-
mediate vicinity  of its origin, forms an
extensive  curve, while it  is  sweeping
across the upper part of the thorax; and
the  intercostals, and the various  circum-
flex  and recurrent branches of the upper
and  lower extremities, run, for the  most
part, more or  less transversely as regards
the parts of the body in which they are
situated.  Many of the arteries are, more-
over,  somewhat flexuous or tortuous  in
their course, and in some of them  this fea-
ture is very strongly characterized.  As a
  vol. n.         26
(Gen. Anat.)                        «**01

 general rule, those which  are distributed
 upon parts which  undergo much latitude
 of motion, or which are liable to frequent
 and sudden changes of position, or of form
 and volume, are the most tortuous.  This
 is exemplified  in the arteries of the iris,
 those of the lips, the heart, stomach, large
 intestines, and especially in the uterus,—
 likewise  in the spermatic arteries, those
 of the spleen,  and the umbilical arteries.
 We frequently see  this  condition acci-
 dentally induced  in the dead body, when,
 in  attempting  to  inject the vessels,  the
 piston of the 6yringe is urged  with too
 much  force; and  as  they  are acted upon
 in a similar manner by the impulse  of the
 blood during life, it has been supposed by
 some anatomists, that even  those which
 are  found perfectly straight after death,
 are, during life,  rendered more or less
 tortuous under the influence of each im-
 pulse of the heart.  Some of the arteries
 present flexuosities,  the object of which
 seems to be to decompose or enfeeble the
 impetus of the blood, and thus to protect
 the organ  to which the vessel is  distri-
 buted, from any injury which  might pro-
 ceed from a too vigorous circulation.  Ex-
 amples of this kind  are furnished by the
 internal carotid, where it traverses  the
 petrous portion of the temporal bone, and
 by the vertebral, at the point at which it
 is about to enter the cranium.
   In most parts of the body, the origin of
 the arteries is but slightly removed from
 the organs which they are  destined to sup-
 ply, and even in their course to their point
 of destination,  they usually distribute ra-
 mifications to  the adjacent parts.  It is
 true, some  apparent exceptions to this
 rule exist,—amongst which the spermatic
 and ovarian arteries, and  the internal ca-
 rotids, as well as  the vertebrals, may be
 enumerated.  This difference,  however,
 is easily explained, by the changes which
 take place in the  relations of the organs
 subsequent to the period of the foetal ex-
 istence.   During the earliest stages  of de-
 velopment,  the  testicles  are   contained
 within  the abdomen, near the  point at
 which the  spermatic arteries take  their
 origin, and the neck being very short, the
 head is, during the first months of exist-
 ence, placed much nearer the heart than
 at a later period.
   All organs do not receive an equal sup-
 ply  of blood-vessels; but  there are few
 which are furnished  with  less than two,
 and to  many the  supply  is  much  more
 abundant.  Nor is the size of the vessels
 always in relation  with the volume of the
 organ to which they are distributed. Those 
302                        ARTERLES.  (Gen. Anat.)
which are concerned in the elaboration of
copious secretions,  as, for example, the
kidneys, the liver, and, in short, the appa-
ratus of glands generally, either have ar-
teries of a large size sent to them, or the
deficiency  of volume is  compensated by
number.  Thus, the size of the  arteries
which are distributed to any part, does not
furnish  an accurate representation of the
quantity of blood which it receives; for
where   a number of small vessels exist,
they may collectively convey more blood
than one of greater volume.   The  mus-
cles, for example, are never penetrated by
large arterial trunks, yet as  numerous
small ramusculi penetrate almost all points
of their circumference, they are  exceed-
ingly vascular, and receive a large quan-
tity of blood.  In some organs which are
supplied with a double  set of blood-ves-
sels, the latter differ from each other in
the quality of the blood which they circu-
late, and also in relation to the functions
which  they subserve.  The lungs, for ex-
ample,  receive   black  or venous blood
through the pulmonary  artery, which is
conveyed to them merely to undergo those
changes which are induced by respiration,
while they at the same time are furnished
with red,  or arterial blood, through the
bronchial arteries,—these latter  convey-
ing to  them the elements of their nutri-
tion and growth, and constituting the in-
struments  of their preservation.  The
liver, in like manner,  presents the  same
type as regards the  distribution of  its
blood-vessels,  with this  difference  only,
that in  it the black blood  is  circulated by
the portal vein instead of an artery.
   But while the  number and  size of the
arteries going to an organ, may vary, the
order in which  they enter its substance
presents everywhere one constant and un-
varying character;—the trunk of the ar-
tery does  not plunge  undivided directly
into the part which it is destined  to sup-
ply, but divides into a number of branches
or ramifications more or  less considerable,
which, radiating from each other, enter its
substance  at different points.   If, by way
of illustration, we  trace the distribution
of any artery into a large gland,  we shall
find it dividing before  it  plunges  into the
organ.   The primitive branches, then en-
tering at different points, take their course
first in the space between the lobes, but
dividing and  subdividing in their course
almost ad infinitum, in proportion as they
become more minute, they follow the line
 of division between the  lobules, then the
 interstices of the granules or acini, until,
 having reached their ultimate state of di-
vision, and attained a degree of tenuity
which renders them invisible to the naked
eye, they finally terminate upon the  ele-
mentary granules, or particles, of which
the gland is composed.
  There are some structures of the  body
which, in the natural state, do not receive
red blood, but  through which a mere co-
lourless fluid is circulated.  The tendons,
ligaments, cartilages, and fibro-cartilages,
are of this kind.   Others seem to be en-
tirely destitute of vessels.  This  is true
of the epidermis, the  hair, nails, enamel
of the teeth, crystalline lens, and probably
the serous membranes proper, entirely di-
vested of the  subserous cellular tissue.
  The symmetry of the arterial system  is
much less  perfect  than that of several
other parts of the body. It is most perfect
in the  extremities,  and in those organs
which are  themselves symmetrical; but
in parts in which this character does not
exist, or is but feebly developed, the  arte-
ries  are more or less symmetrical.  In
this  respect, there  does  not seem to be
much difference  between them and the
veins.   In  the abdomen  and the lower
part of the  thorax, the preponderance of
symmetry is in favour  of the arteries; for
both the spermatic  arteries proceed from
the aorta, while one only of the correspond-
ing veins  terminates in the vena cava,—
the left opening into the  emulgent vein;
and while the intercostal and lumbar ar-
teries proceed from the aorta, a portion of
the corresponding veins,  instead of com-
municating  with the vena cava,  form the
vena azygos and demiazygos.   In the up-
per part of the thorax, however, the heart
is not only  inclined to the left side, but
the branches  which arise from the arch
of the aorta differ on the right and left
sides, whde the right  and left brachio-ce-
phalic veins are symmetrical.
   $ 2. Anastomosis and  termination of
the arteries.  The arteries, though divided
and  subdivided almost to infinity, in the
substance of the tissues  and  organs, are
extensively  associated with each other by
anastomosis.   Communications are formed
between the trunks, the branches, and the
most minute ramifications.  Such connex-
ions, however, are not established in the
same manner  in all parts of the vascular
system; nor are they equally numerous  in
the several portions of the arborescent ar-
rangement which it presents.   There are
comparatively few,  the  nearer we ap-
proach  the centre of the  circulation; but
towards its periphery, where the minute
divisions of the arteries acquire a capillary
tenuity, they become so multiplied,  as  to 
ARTERIES.  (Gen. Anat.)
303
 represent a complete net-work of vessels,
 inosculating  with each  other in a most
 complex manner.
   Sometimes two trunks or two branches
 join each other at an acute angle, to form
 a single  trunk or branch, which either
 pursues the course of the vessels by which
 it is formed,  or departs more  or less con-
 siderably from it.  This is exemplified in
 the connexion which  is  formed in  the
 foetus, between the  pulmonary artery and
 the aorta, by the ductus  arteriosus, and in
 the vertebral,  and the anterior arteries of
 the spinal marrow. The  first of these con-
 nexions is confined to the period of festal
 life, and is  destroyed after birth, by  the
 obliteration of the ductus  arteriosus. Some-
 what more frequently, two arteries, run-
 ning more or less parallel, are  united by
 transverse branches, as is observed in  the
 anterior cerebral arteries of the right and
 the left side, the connexion between these
 and the vertebrals, and  that which exists
 within  the substance of  the placenta,  be-
 tween the two umbilical arteries.  A simi-
 lar association or anastomosis  is, more-
 over, observed in some instances between
 the smaller ramuli; as, for example, where
 two parallel  ramifications  distribute their
 minute capillaries into  the substance of
 an organ, and where the series of each
 intersect it  at right angles.  By far  the
 most ordinary disposition of the anasto-
 mosis  is that which takes place between
 the minute ramuscular extremities of  the
 vessels, reduced to their ultimate state of
 subdivision.   Here the  anastomosing  ra-
 musculi approach each  other,  and  unite
 by their extremities, to form arches, with-
 out there being  any means furnished  for
 determining  precisely the point at which
 the one terminates and the  other  com-
 mences.  This arrangement  is observed
 in every part of the periphery of the vas-
 cular system,  and is  particularly impor-
 tant in  the vicinity of the movable articu-
 lations, and  in those situations at which
 the termination  of different arteries is
 brought in relation with  each  other,  inas-
 much as these free  anastomoses furnish
 collateral channels,  through which   the
 blood may be conveyed to its point of des-
 tination, when by accident, or  an opera-
 tion for aneurism or any other purpose,
 the main trunk,  or an important arterial
 branch,  has  been obliterated.   It is,  in-
 deed, upon this free anastomosis, that the
 success of such  operations depends (see
 Aneurism);  and  in  several cases where
 spontaneous obliteration of even  the great
trunk of the  aorta has taken place, these
collateral channels have  compensated  for
the injury sustained, by transmitting suf-
ficient blood to preserve the vitality of the
parts interested. Some of the arches form-
ed by these inosculations are exceedingly
minute, while  others are larger, and dis-
tribute from their convex surface,  numer-
ous ramuli to  supply the adjacent parts.
This  arrangement is particularly manifest
in the arteries of the mesentery and in-
testines, where a succession of arches is
thus  formed,   each  series  becoming, as
they  progress towards the periphery, more
and more minute.   The same  disposition
is observed in the delicate vessels of the
iris, and in those of some other parts of
the body.
   The vessels, in their ultimate state of
division  and subdivision, present a deli-
cate  arborescent arrangement, to which
the denomination of capillary vessels has
been  applied.   These attenuated vessels
were unknown to  the ancients, because
they  were not acquainted with the art of
injection,  which has done so  much for
anatomical science in modern times; and
as they could not be traced with  the na-
ked eye, they escaped observation.  But
at the present time, notwithstanding the
multiplied  and  luminous  investigations
which have been directed to the  subject,
and   notwithstanding the  collateral aids
furnished  by  minute injections, the mi-
croscope, and  other improved means of
conducting researches upon objects so mi-
nute  and complicated,  much diversity of
opinion exists in relation to the character
of these  vessels,  the manner  in which
they  terminate, and the nature of their
connexions with each other, and with the
veins and lymphatics.
   As regards the first question, the opin-
ions  which have been advanced  may be
referred to two heads:  1. those who re-
present  the capillary vessels as forming
a system interposed between the termina-
tion of the arteries and the radicles of the
veins; and 2.  those  who merely view it
as the transition from  the arteries to the
veins, and composed of the terminations
of the one, and the commencement of the
other.
   The first of these opinions has been ad-
\^cated by Bichat and Autenreith. The
latter has indeed affirmed, that  the capil-
lary  vessels  represent,  in  the  order of
their  arrangement, the type of the vena
portarum ;—that each  capillary branch,
like the trunk of that vein,  is ramified at
both its extremities,  and that by one se-
ries of these ramifications it anastomoses
with the termination of the arteries, while
the other series forms a similar  connexion 
304
ARTERIES.  (Gen. Anat.)
 with the veins; so that the entire arrange-
 ment forms a system apart, interposed be-
 tween the termination of the arteries and
 the  commencement of the veins,  the ra-
 mifications of which convey all the mate-
 rials of nutrition  to the various tissues in
 which they are distributed.  But notwith-
 standing  considerable  modifications are
 observed, both in the texture and vitalism
 of these vessels,  and in the properties of
 the  fluids which  they circulate,  results
 furnished by minute injections and  other
 means  of investigation, are unfavourable
 to the inference of Bichat and those who
 concur  with  him,  and positively disprove
 the hypothesis advanced by Autenreith.
 Nor does there  seem to be  any  valid
 foundation  for the  belief advocated  by
 Haller,  Hewson, Soemmering, Bichat,
 Chaussier, and others, of the  existence
 of a distinct set  of attenuated capillary
 vessels, merely capable of circulating a
 colourless  watery fluid, which they have
 denominated exhalants.  It is highly pro-
 bable, nevertheless, that some  of the ca-
 pillary vessels proper, attain such  an ex-
 treme degree of tenuity, as to be incapa-
 ble of circulating red  blood,  and which
 consequently merely convey a white or
 transparent fluid.   Such an opinion seems
 at least to have some foundation, when we
 attend   to the appearances presented  by
 these vessels in  some  of the tissues, and
 under different modifications of their vital
 acts.  Certain it is, that in many parts of
 the body, no capillary vessels  conveying
 red blood  can be discerned in a state of
 health; yet when these same structures
 become the seat of disease, they are per-
 meated  by an infinity of red vessels, which
 form a  complex vascular, reticulated ar-
 rangement, presenting  the same appear-
 ance as the vascular ramifications observed
 in other tissues.   In explanation  of this
 phenomenon, it  has been affirmed,  it is
 true, that  such vessels  always convey red
 blood, but as the stream is so minute, being
 merely  composed  of a single  series  of
 globules,  the natural red colour is  con-
 cealed  in consequence of the quantity be-
 ing too small to manifest the  usual char-
 acteristic.  But while this  argument is
 somewhat corroborated by certain physical
facts, it  is far  from  being  conclusive.
Vieussens,  Boerhaave,  Haller,  and
many physiologists in modern times,  have
contended  for the existence  of vessels,
continuous with the red capillaries, which
merely transmit a transparent  or colour-
less  fluid; and  Bleuland even asserts
that he, in one instance, succeeded in de-
monstrating these vessels. Notwithstand-
 ing, therefore,  it has been contended by
 Prochaska, Mascaoni, &c., that there
 are  no vessels  of the  kind  in  question,
 there  are  certain phenomena of circula-
 tion, nutrition,  and secretion, which, in
 the  present state of our  knowledge, it is
 difficult  to explain  in any other manner
 than by a  reference to  such  instruments.
 Broussais, indeed,  and  some other mo-
 dern pathologists, have not only admitted
 that they exist, but have likewise imputed
 to them an important agency in the vari-
 ous  sub-inflammations, and many other
 pathological  states.   It is reasonable to
 presume, from the absence of red capil-
 lary vessels in the cartilages and many of
 the  other  white tissues,  and from  their
 extreme  paucity in  some of those which
 are  more highly coloured, that nutrition,
 secretion,  &c,  could not be adequately
 performed  by the small number of vessels
 which can be rendered apparent by injec-
 tion  or other means, and without the con-
 current agency of others, which  though
 so attenuated as to  escape our means of
 investigation, probably exist,  and form an
 important part of such portions of the or-
 ganization.
  A more  important question is, the man-
 ner in which the arteries terminate; the
 nature of their relations at this point with
 the tissues to which they are distributed;
 and the character of their connexions with
 the veins and lymphatics.
  Aristotle  supposed that  the  arteries
 end  by blind extremities  in the tendons,
 and through these latter terminate in the
 bones.   Aretjeus, Galen, and others of
 the ancients, corrected the hypothesis of
 Aristotle;  but, embracing the opinion
 that  these  vessels have open extremities,
 they supposed that the blood thrown from
 them forms  a  kind of parenchyma, of
 which the  liver, kidneys, spleen, &c, are
 composed.  A modification of the doctrine
of the  open extremities of the  capillary
arteries,  is advocated by  respectable au-
thority at the present time; and although
a majority of anatomists and physiologists
believe that  the arteries are continuous
with the veins, the opposite-sentiment has
many able  supporters, and should not be
too hastily  rejected.  The  results obtained
by minute  injections, and the phenomena
presented by the capillary circulation in
 the transparent animals, prove incontest-
ably, that  the blood passes in continuous
streams from the arteries into the veins;
but it  is not so satisfactorily proved that
these streamlets are  contained within pro-
per vascular tunics.  Haller, and many
before his time,  believed that the vessels 
ARTERIES.  (Gen. Anat.)
305
open  by pore3, through which the blood,
or the  materials formed from it,  escape
into the surrounding parts.  This view
has been advocated by many modern ana-
tomists,  and  especially by  Prochaska,
Mascagni, Wedemever, Rathke, Home,
Gruithuisen, Fodere,  and many others.
Home represents that he discovered these
pores in the vessels of the suprarenal cap-
sules, but they were too minute  to trans-
mit a globule of blood, and merely allowed
particles of oil to exude.   Wedemeyer
found the arteries  of the  air-cells of the
salamander's lungs gradually losing their
tunics  in the parenchyma of the organ,
and presenting a perforated or sieve-like
arrangement,  through  which the  blood
globules  were  transmitted  (Uber den
Kreislaufe des  blutes,  in Meckel's Ar-
chives fur Anat. und Physiol.  1828.  p.
348.); and a similar arrangement has been
observed by Andral in the vessels of the
spleen.
   Whether these pores exist or not, for
the deposit of the  materials  of  nutrition
and secretion, it seems to be highly pro-
bable, that while there is a direct continu-
ity even by their tunics between some of
the arteries and veins, there  is interposed
between others a species of parenchyma,
or organic substance,  through  which  a
portion  of the blood circulates in numer-
ous  streamlets, without being contained
within any proper vascular tunics, but in
immediate contact with molecules of the
tissue itself. This view of the subject has
been advocated by Wolff, Hunter, Dol-
lenger, Gruithuisen,  Oesterreicher,
Wedemeyer, Baumgartner, Willbrand,
Kaltenbrunner, &c, who have adduced
many forcible arguments in its support.
By them, it is represented, that where the
capillary vessels attain  an extreme tenu-
ity,  their tunics entirely disappear,  the
blood beyond that point  being merely cir-
culated  through channels,  composed, ac-
cording to Dollenger, of a  kind of mu-
cous organic substance, a part of it in this
transit  being  converted into the  proper
substance of the tissues, and into secre-
tions, while the  other  portion  continues
its course to the radicles of the veins and
lymphatics, which it enters, and is return-
ed to the centre of circulation.   In this
muco-organic  substance, therefore, he re-
presents that  important  metamorphoses
take place in the blood,  as well as in  the
organic solids.  The former is  in  part
transformed into organic elements and se-
cretions, or becomes solidified and assimi-
lated to  the property of the tissue  in which
it is deposited, while the latter are at  the
                  2b*
same time liquefied, and reconverted into
blood, which is again conveyed  by the
veins and lymphatics on the devious round
of the circulation.  (Was ist absonderung
und wie gescheicht sie ?  p. 25, 26.;  also,
Denkschriften der Kbniglichen Akad. der
Wissenschaft. zu Munchen. 1809.) Will-
brand, adopting a  similar opinion, has ex-
tended the principle still farther.  He de-
nies that injections and microscopical ob-
servations, made  on  the circulation  in
transparent animals,  should  be admitted
as conclusive evidence of the  continuity
of the arteries with the veins.  He even
asserts that there is, properly speaking,
no circulation of the  blood, but that the
heart and arteries merely distribute that
fluid to all parts  of  the body, and that
when it arrives at  the termination of the
capillary arteries, it all undergoes a meta-
morphosis, by which it is in part solidified,
or organized, and in part transformed into
secretions, while  the  solids are, at the
same time, liquefied,  to form the venous
blood, which is generated at  this point
from the organized solids,  and is  not a
mere continuation of the arterial blood.
(Isis: also, Journal Complimentaire des
Sciences Midicales.)   According to this
hypothesis,  a  solid barrier  is  interposed
between the termination  of the  arteries
and the  origin of the veins,  which,  how-
ever, is  incessantly forming and decom-
posing;  for every particle  of blood,  as
soon as it has reached that point, is solidi-
fied, or forms secretions; but the  state  of
solidity is merely temporary, inasmuch as
it is as speedily broken down, to form the
venous blood, and the fluids  circulated  by
the lymphatic vessels.
   An opinion somewhat similar has  been
advocated by Spitta (De sanguinis dig-
nitate  in path., &c.   Rostochii,  1825.),
Runge (Zur lebens-und Stoffwissenschaft
des Thieres.  Berlin, 1824.), Sachs (in
Heusinger's zeitschrift fur die organische
Physik.   Eisenach, 1827.),   and  Schulz
(Ueber Blutbildung und Blutbewegung,
in Meckel's Archives fur Anat. und Phy-
siol, p. 487. 1828.).   Arguments  in  sup-
port of it have been adduced from  the dis-
proportion between the quantity of the ar-
terial and venous blood; the dissimilarity
in the properties  of the two fluids; the
suddenness  with  which  the  transition
takes place, the change being too palpable
to be effected while the blood is  flowing
in a continuous stream; the phenomena
furnished by microscopical observations;
and from the consideration, that nutrition
and secretion could not be  accomplished
if the streamlets of blood  merely flowed 
306                        ARTERIES.  (Gen. Anat.)
onward?, from the arteries into the veins,
inclosed  within  the  capillary  vessels.
There can be but little doubt that some
of the individuals mentioned have extend-
ed  their inferences beyond  their  legiti-
mate boundaries, and have formed conclu-
sions  which cannot be justified by fact;
yet we think it equally clear, that those
who have adopted  the opinion,  that  the
blood nowhere circulates  in immediate
contact with the parenchyma of the tis-
sues, are equally in error, since, conform-
ably to their hypothesis, the acts of secre-
tion, nutrition, and exhalation, could  not
be  accomplished, inasmuch as the blood
being everywhere  contained  within  the
tunics of the vessels, and the arteries be-
ing continuous with the veins, the  mate-
rials which are the  product of these acts,
could not be separated from the blood.  It
is true, that  Prochaska, Mascagni, and
some  others  of the opponents, have  ad-
mitted that the coats of the  vessels  are
perforated  by  minute  pores,  and that
through these, particles escape; but if this
be  granted, they defeat their own argu-
ment, and  virtually adopt the sentiment
of those  who maintain that a portion  of
the  blood merely  circulates in streamlets
which permeate the organic parenchyma
in direct contact with its  substance, and
without being inclosed in any vascular tu-
nics.  Nor can the  inceptive condition of
the  blood-vessels which is observed  in the
incubated egg, in the embryo of more per-
fect animals, or the development of new
vessels in a part  of recent formation, ad-
mit of any other explanation.  Thus, for
example, if we watch the process by which
these results are achieved, we shall first
perceive in the substance which is to be-
come the seat  of the  vessels, a few  iso-
lated  points,  of a reddish colour.   From
these points, which are particles of blood
developed in the mass,  radii afterwards
shoot out in various directions, which are
permeated by as many streamlets of blood,
advancing from the central point towards
the  circumference.   Many of these radii
finally meet, or intersect each other, thus
forming  numerous  inosculations; and  an
infinity of minute channels, conveying red
blood, are in this manner  formed, which
represent the rudimentary type of blood-
vessels ;  and by subsequent c'.ianges, each
of these channels  becomes  supplied  by
proper vascular walls, furnished  in part
by the solid mass which they traverse, but
in part likewise by the plastic powers  of
the  blood itself.   In corroboration  of the
same view, it may moreover be remarked,
that when the transparent part ofa living
animal  is  irritated,  streamlets  of blood
globules are  seen  rushing from  every
point towards the centre of irritation, and
these streams continue to increase when
the irritation is protracted, until the whole
tissue, which  was previously,  to all ap-
pearances,  bloodless, seems to be perme-
ated in  every possible direction,  with my-
riads of capillary channels, circulating red
blood, all communicating with each other,
but  constantly  changing their  direction
and the order of their connexions.
  From what has been said, it is manifest
that our opinions upon this obscure and
intricate part  of anatomy, must be, to a
great extent, merely conjectural, and that
where  demonstration is so  difficult, cau-
tion  should be  observed in  forming posi-
tive  conclusions.  The authority  is re-
spectable upon both sides of the  question
at issue, but  we  are  inclined,   notwith-
standing the arguments adduced by Leu-
wenhoeck, Haller, Spallanzani,  Pro-
chaska, Bichat, Rudolphi, Muller, and
others, to  prove that the blood does not
pass from the arteries to the veins in any
other manner than by a continuity of ves-
sels, to adopt an opposite  opinion.  The
minute  and  elaborate  investigations of
Wedemeyer,  as well as many other facta
and arguments which might be  adduced,
serve to demonstrate,  that  the arteries
manifest different modes of termination,
according  to the relations of their capil-
lary extremities, and the offices they have
to perform. 1.  The largest capillary ra-
mifications are continuous with the radi-
cles of the  veins, the blood throughout the
whole  of its  transit from the one set of
vessels  to  the  others,  being contained
within proper vessels.   2.  Other stream-
lets of blood, of greater tenuity,  permeate
the parenchyma of  the tissues, through
numerous  channels, the walls  of which
are formed by the  tissue  itself, without
the intervention of  any vascular tunics.
3. There are  no facts  demonstrative of
any direct continuity of terminal extremi-
ties of the arteries  with the radicles of
the lymphatics,  but,  on the contrary, all
that is known on the subject, seems to fa-
vour an opposite  conclusion.  It should
nevertheless be remarked, that Mascagni
and Lauth have traced lymphatics taking
their origin from the tunics of the arte-
ries.  4. The  arteries probably  do not
communicate directly with the excretory
vessels  of  the glands, as was supposed by
Haller, but become divested  of their tu-
nics in the  immediate vicinity of the radi-
cles  of those  vessels,  so  that the blood
which  is appropriated  to the purposes of 
ARTERIES.  (Gen. Anat.)
307
secretion, is placed  in  immediate contact
with the substance  of the organ, and cir-
culates in the interstices of its molecules.
This seems to be the case in the liver and
kidneys.   5. The same  disposition appa-
rently exists in the  termination of the ar-
teries upon the exhalant surfaces.   Be-
yond the point to which the tunics of the
vessels  extend, the blood  probably  tra-
verses capillary channels which permeate
the  parenchyma of the tissue, until  it
finally reaches  a  more porous arrange-
ment, through which the serous fluid  per-
colates  until it escapes  upon the surface
of the  membrane.   As  regards the ab-
sence of all direct communication between
the blood-vessels of the liver and the radi-
cles of the excretory vessels, there can be
but little doubt, as  injections have failed
to demonstrate it.   Even Muller, who is
one of the most recent and able opponents
of the opinion which we have adopted, is
obliged  to concede this point.  He  re-
marks, that even with the  assistance of
the air-pump, minute injections could not
be  made  to pass from  the  blood-vessels
into the  excretory duct of the gland (Mi-
hrometrische messungen der Acini  und
secretfuhrenden Kanale der Drusen im
injicerten, &c, in Meckel's  Archives fur
Anat. und, Physiol, p. 58. 1830.); and in
another place he observes,  that when air
is blown into the vena portse, the liver is
easily inflated,  and  the air passes with fa-
cility into the vena cava, and even to the
heart, but cannot be forced  into the radi-
cles of the hepatic duct.  ( Ueber den kries-
laufe des blutes in  der Leber der jungen
Salamanderlarven. Op. Cit. p. 191. 1829.)
   \ 3.  Structure of the Arteries.   The
arteries are composed of three  concentric
layers or tunics, each of which presents
properties peculiar to itself.  These  are
the external, or cellular, which  unites the
vessel with the  surrounding parts;  the
middle, fibrous, or elastic, sometimes  call-
ed muscular coat; and  the  internal, se-
rous, or proper tunic  of   the vascular
system.
   a. The cellular  coat of the  arteries is
flocculent on  its outer surface, by which
it is connected with the surrounding parts,
and  is composed of compact cellular tis-
sue, which is  more firm  and filament-
ous than that  which occupies  the inter-
stices of the organs.  These filaments are
closely interwoven  with each  other, and
are ofa whitish appearance.  Those, how-
ever, which compose the outer part of the
tunic, are more  loosely united, and  are
more flocculent, than  those which  are
deep-seated;—the  latter being  generally
so condensed, that the proper structure is
only seen well, when the part is submitted
to forcible traction.  Scarpa has main-
tained that this  cellular  tunic  does  not
appertain specially  to the  arteries,  but
merely consists of a portion of the cellu-
lar tissue which is  common to all the or-
gans.   There are,  however, qualities by
which they are palpably distinguished. It
is much more  compact and  resistant; its
filaments are more closely interwoven; its
interstices never become the seat of adi-
pose or serous deposits, and when its ex-
ternal surface is  detached from the  sur-
rounding parts with which  it  adheres, it
may be  stripped  off from  the adjacent
fibrous coat, in form of a continuous mem-
branous cylinder.    This separation is the
more  easily accomplished, because of the
extreme  tenuity of the adhesion between
the two tunics
  This  coat, which is elastic and highly
extensible, is  at  the same time endowed
with  great strength.   It  preserves  the
flexures  of the arteries, which  disappear
as soon as it  is divided or destroyed.  It
imparts to them their principal faculty of
resistance, and is the only one which sus-
tains a ligature when this is applied to an
artery, both the others, in consequence of
their  extreme fragility,  being  easily di-
vided ; and in most cases of aneurism, it
becomes more or  less distended, and forms
the proper sac.
  b. The elastic, fibrous, or middle coat,
sometimes improperly denominated mus-
cular coat.   This  is by far the thickest
coat of the arteries, especially of the large
trunks and primitive branches, and it  is to
this structure that these vessels are main-
ly indebted for their elasticity.   Meckel
has also  affirmed  that the principal resist-
ance of the arteries is owing to the fibrous
tunic; but we think this expression needs,
some qualification, inasmuch as the elastic
fibres of which it  is composed, are very
fragile, and frequently give way, leaving
the column of blood to be sustained by the
cellular coat,  as in  aneurisms.  This tunic
is of a lightish yellow colour, sometimes
presenting a very slight shade of pink. It
is more or less  compact, highly elastic,
and so exceedingly fragile, that it gives
way, or is divided, under very slight force.
Hence, as was long since  demonstrated
by Desault and Jones, it is always  sev-
ered by the constriction of a ligature ap-
plied to  an artery.  When carefully ex-
amined,  it is found  to be  composed of
fibres, or rather of very thin lamina?, which
form concentric circles, twining round the
circumference of the  vessels,  but  being 
308
ARTERIES.  (Gen. Anat.)
generally a little oblique or spiral in their
arrangement,  so that the  circles are  in-
complete.  The fibres are intimately  in-
terlaced with  each other, and  their con-
nexion is rather effected by this interlace-
ment than by  the intervention of cellular
tissue.  Hence, as the filaments are very
fragile and delicate, they can be  easily
separated.
  The fibrous coat exists  in all parts of
the arteries,—in the ramifications, as well
as in the  trunks  and  branches.   Boer-
haave,  and some  others,  supposed that
the arteries of the brain are destitute of
it  But  this opinion is not correct.   It is
merely thinner  there than elsewhere, in
consequence of which, those vessels, when
divided, collapse like veins, while  in the
other arteries, the elastic coat maintains
their proper cylindrical configuration when
they are empty or severed transversely.
But whUe  the elastic tissue  exists in all
the arteries,  it  does not seem to present
precisely the same properties at all  points.
It was remarked  by Hunter, that it  is
redder and more  irritable in the small
ramifications  than in  the large trunks;
hence he conceived, that  in the former,
contractility was more  energetic,  and in
the latter, elasticity.
  Besides the circular fibres of the arte-
ries, Willis and  some of the  older ana-
tomists described a longitudinal series as
appertaining to these vessels.   No such
arrangement has been demonstrated, and
the only approximation  to such a  condi-
tion, that we have been  able to discover,
consists in a  few  slight longitudinal folds
which we have occasionally discovered in
the large  trunks,  and  especially  in the
pulmonary artery.
  The fibrous coat of the arteries,  which
was generally regarded as muscular, was
first shown by Bichat to possess very dif-
ferent properties, and the  subsequent  re-
searches of De Blainville,  Dupuytren,
Beclard, Mascagni, Hauff, Meckel, and
others, have demonstrated that it  should
be regarded as a peculiar tissue, to  which
the appellation of elastic has been applied.
The same species of tissue  exists in va-
rious  parts of the body, as,  for example,
in the trachea  and bronchia, in some of
the excretory  ducts, and in the interstices
between the arches of the vertebra, where
it forms the  yellow ligaments.  It  also
forms the ligamentum nucha*,  the  fibrous
covering  of the spleen, the  ovaria, the
penis, &c.  It differs from muscle in struc-
ture,  in chemical composition, and in vital
endowment.   Its fibres are less parallel,
and are  infinitely  more fragile.   They
have not the colour of muscular fibres, and
are not, like them, united by cellular tis-
sue, or at least if that tissue does exist, it
is  in  such small quantity, and 60 exceed-
ingly delicate, as to exercise a very trivial
agency.  The  fibres,  moreover,  can be
much more easily separated.   It also dif-
fers from the  fibrous arrangement of the
tendons, in characters which are  equally
palpable.
  The fibrous coat of the arteries, when
submitted to  the drying process,  parts
with but little water, assumes a deep yel-
lowish-brown, and sometimes even a black
colour.  By immersion  in water, its elas-
ticity is restored.  It is tardy in taking on
the putrefactive process, and often resists
even until the  surrounding parts  are en-
tirely destroyed.  It also differs from mus-
cle in  the  following  particulars:  It  is
completely insoluble in boiling water, so
that  water in  which it has been boiled
even  for several hours, throws down no
precipitate when powdered galls are add-
ed.  Nor is it either softened or dissolved
by cold or boiling acetic acid, but  the ni-
tric,  sulphuric, and muriatic acids, dissolve
it readily, even when diluted.  This solu-
tion, however, manifests no precipitate on
the addition of an alkali, or  of the ferro-
cyanate of  potassa?, which  it  should  if
it  contained fibrine. (Berzelius. Traiti
de Chimie.  VII.  84.  Paris,  1833.)  It
will  thus be seen, that in all these parti-
culars,  the  elastic  fibrous  tissue differs
from muscle. The predominant ingredient
of the latter, it is well known, is  fibrine;
—in the former, this principle  cannot be
detected by the most careful  analysis.
  As regards its endowments,  it presents
properties equally  striking,  by which it
contrasts with muscle.  In the  one, elas-
ticity constitutes the most remarkable at-
tribute ;—in the other, it scarcely exists.
In the arterial tissue, but slight evidences
of irritability  can be  developed  by  gal-
vanism or other means: the muscular tis-
sue,  on the contrary,  possesses this pro-
perty in a remarkable degree.  Thus, al-
though the  arteries display  more or less
contractile force in the circulation of the
blood, this  contraction is very different
from  that which takes place in the mus-
cular system.
  c.  The internal tunic of the arteries.
(Tissu kysteux angiial,  De Blainville;
Tela vasorum communis, Weber et alias.)
This tunic  or membrane is remarkably
thin,  and presents a whitish homogeneous
appearance when  examined  in connexion
with  the parts to which it adheres, but is
transparent when perfectly isolated.  It is 
ARTERIES.  (Gen. Anat.)
309
compact, fragile, smooth, polished and lu-
bricated upon its free surface,—rough and
uneven on its external face, by which it
adheres to the  fibrous coat of the  arte-
ries and to the muscular substance of the
heart.  This surface adheres so closely in
the arteries, that it cannot, in the  fresh
state, be separated to any extent from the
adjacent fibres.  It has, indeed, been re-
marked by Albinus (Annotat. Academica.
Lib.  IV.  cap. 8. p.  30.), that there seems
to be a continuity of substance between it
and  the  elastic fibres, and  that they are
not.united by cellular  tissue.  The same
remark has been repeated by most modern
anatomists, and even by Bichat.   There
are reasons, hqwever,  for presuming that
the inference is not correct.   By immer-
sion  in boiling water,  by  the process of
boiling, and even  by protracted macera-
tion, in water frequently renewed, it may
sometimes be separated in portions of con-
siderable  extent, which could not be ac-
complished if it possessed  a direct con-
tinuity of substance with the fibrous struc-
ture.   The presence of this delicate cel-
lular tissue  is, moreover, rendered proba-
ble by the phenomena presented by in-
flammation of the vascular tunics, by the
frequent development of calcareous trans-
formations beneath  the lining membrane,
and  by  the  occurrence of tuberculous,
atheromatous, and other degenerations in
the same  situation.   In the cavities of the
heart,  indeed, the intervention of cellular
tissue between the lining membrane and
the muscular substance of the organ, can
be  satisfactorily demonstrated,  because
here the  delicate  vascular  tunic can  be
detached with great facility.
   This membrane is common to the whole
vascular system, the type of which it ac-
curately represents.   The  heart  is its
great centre, and after lining the cavities
of this organ, it follows the ramifications
of the arteries, the  veins, and lymphatics,
accompanying all their divisions and sub-
divisions,  to their  ultimate  terminations,
and  constituting their proper lining.  It
does not, however, present  the same pro-
perties and distribution in all parts of the
vascular system.  In the heart, it  is re-
flected over  the muscular bands or col-
umns.   At the  orifice of the  aorta and
pulmonary arteries, it is  doubled  upon
itself, to  form three uniform lunated du-
plicators, with free or floating margins,
denominated  semilunar valves, which pre-
vent the  blood  from being thrown back
into the ventricles during their dilatation.
(See Heart.)   It also forms the mitral and
tricuspid  valves, and  the valves of Eu-
stachius  and Thebesius.   In  the arte-
ries, it is distributed uniformly,  except at
their bifurcations, at which points it seems
to be somewhat thickened, and contributes
to form a prominent margin, by which the
diverging streams of blood are more rea-
dily separated from each other.  In most
of the veins,  however, as well  as  in the
lymphatics,  it  forms  numerous duplica-
tures or valves, all having their free edges
directed  towards  the  heart.   Of these,
some are  double, and are placed opposite
to each other, while the majority are sin-
gle, and only occupy one side of the ves-
sel.   It is thicker and possessed of more
density in the arteries  than in  the veins,
and  the  lining  membrane of  the latter
presents  these properties in a greater de-
gree  than that of the lymphatics,  which,
according to De Blainville, is much more
spongy, and  approximates  nearer  to the
properties of a mucous, than to those of
the proper vascular tissue.
  The intimate  organization of this tis-
sue has not been very satisfactorily deter-
mined.  Bichat regarded it as a kind of
epidermis, destined to protect the internal
surface of the  vascular system.   Mas-
cagni affirms that its free surface ex-
hibits a kind of tomentose  arrangement,
which represents the orifices of lymphatic
absorbent vessels thus taking their origin
from  the  inner surface  of the arteries.
He hence conceives, that it is composed
entirely of these minute vessels, and has,
from  this circumstance, denominated  it
lymphatic tunic. (Prodromo delta Grande
Anatomia. I. 193. Milano,  1821.)  When
brought under the field of the microscope,
it presents, according to Milne Edwards,
a number of globules  3^ millemetre, or
tsV<r °f a French inch in diameter.  Others,
however,  have asserted  that it furnishes
no indication of either globules, fibres, or
cells.  De Blainville, and Hodgkin and
Lister,  have nevertheless affirmed that
the lining membrane of the arteries ex-
hibits a  kind of serpentine or spiral ar-
rangement.   Inasmuch, however,  as this
appearance could only be observed in the
arteries,  it is probable  that  it was owing
to the elastic fibres not being completely
detached  from  the outer surface  of the
membrane.  It is destitute of both vessels
and nerves:  at least, neither have been
satisfactorily traced  into its   substance.
This  opinion has been advocated by Ru-
dolphi, Soemmering,  and  others,  and  is
apparently borne out, both by examination,
and by analogy.  The delicate cellular
tissue which connects this membrane to
the fibrous tunic, is traversed by numerous 
310                        ARTERIES. (Gen. Anat.)
minute vessels, which,  in a state  of in-
flammation, were found by Ribes, forming
a very delicate plexus upon the outer face
of the proper vascular tunic.  Nor is the
vascularity of the membrane proved by
the deep-red suffusion which it presents
in disease; for its tenuity  is such, that
this  appearance can be  easily explained
by the redness which is seated beneath
showing through it
  From all these considerations, we  are
inclined to adopt the conclusion, that the
lining membrane of the vascular system
should be classed amongst the simple un-
injectible tissues.   It indeed consists of a
thin  porous or  permeable pellicle, every-
where lining the  organs of circulation,
and  presenting most  of those  properties
which distinguish  the serous membranes
proper.  This analogy  is,  moreover,  de-
monstrated by the distribution of the vas-
cular tissue,  by the changes which it un-
dergoes in disease, and by its vital pro-
perties.  De Blainville has, indeed, af-
firmed,  that this  tissue, like the serous
membranes, represents a sac reflected and
ramified, and everywhere continuous, the
centre of which is the  heart,  but  which
branches from this point throughout every
part of the system, thus forming the in-
finity of channels which are represented
by  the  arteries,  veins,  and lymphatics.
Hence, these ramifications, in advancing
from the  centre  towards the  circumfer-
ence, diminish in  size, until they merely
form capillary tubes, ending in the paren-
chyma of the tissues,  or continuing with
the  radicles of the veins.  It  should  be
observed,  moreover, that in those situa-
tions where an impulsive agent is  requi-
site,  the  fibrous  tunic is  superadded,  to
perform this office; but in the extreme
capillary ramifications,  the  minute chan-
nels  are merely surrounded by this deli-
cate  membrane, exterior to which there
is nothing but the parenchyma of the tis-
sue which they traverse. (De Blainville.
Cours de  Physiologie ginirale et compa-
rie.  II. 280.)
   This view, so far as properties of struc-
ture are concerned, is unquestionably cor-
rect Yet, if with Bichat, and the  unani-
mous sentiment of  the present day, we
assume as the type of the serous mem-
branes, a sac reflected,  and without open-
ing, it will be difficult to reduce the type
of the vascular system  to  this standard.
It is not a reflected membrane; its rami-
fications  do not  terminate  in  blind ex-
tremities,  but  a portion of them become
gradually  lost  in the porous parenchyma
of the tissues,  while others communicate
directly with  the radicles of the  veins.
But be this as it may, there  is  certainly
an identity of structure, and the only rea-
son why their  types  cannot  be made to
correspond is,  that our definition  of the
serous membranes is too exclusive. What-
ever may be  their form, we  are satisfied
that Chaussier,  Rudolphi, Ribes,  and
others, have correctly represented the se-
rous membranes as merely consisting of
a kind  of inorganic,  condensed pellicle,
limiting the  surface of organs  and cavi-
ties, and that the tissue under considera-
tion  is  of  the same  character.  All the
apparent vital  phenomena  presented  by
either, are  attributable, for the most part,
to modifications taking place in the deli-
cate cellular  tissue,  which  everywhere
constitutes the  connecting  medium be-
tween the  membranes and the  surround-
ing parts,  and which  is traversed by an
infinity of vessels.
  This  tissue is possessed of considerable
elasticity, and its extensibility is so great
that in true aneurism, in varicose veins,
in dilatation  of the cavities  of  the heart,
and in that variety of aneurism which has
been  described  under the appellation of
internal mixed, we find it becoming inor-
dinately distended,  without  being rup-
tured.  The same extensibility is mani-
fested in the great dilatation of the uterine
arteries and veins which takes place dur-
ing pregnancy.   Its powers of resistance,
however, are very feeble.   It  is remark-
ably fragile,  and  it frequently gives way
under very slight force.
   The  moisture which constantly exists
upon the  internal surface  of the lining
membrane of the vessels,  and which has
been regarded by some as the result of a
secretory process, and by others as de-
pendent upon  the serum of the blood, is
probably merely an exhalation from the
capillary ramifications which  are distri-
buted to the tunics of the vessels, similar
to that  which takes place from all the se-
rous  surfaces.
   The  arteries, while they constitute the
proper  instruments for the transmission
of the  blood, are themselves abundantly
supplied with  minute blood-vessels  de-
nominated vasa vasorum.   They are  ex-
ceedingly small, and probably, in all cases,
derive their origin from some other artery
 than that which they are intended to sup-
ply.  They plunge at first into the cellu-
 lar tunic,  in which  they ramify exten-
 sively,  the ramusculi being distributed for
 the  most part in radiated series.  Many
 of them are  also distributed  upon  the
 fibrous tunic, and reach the delicate eel- 
ARTERIES.  (Gen. Anat.)
311
lular tissue by which it is united  to the
lining membrane, where they form  a very
fine vascular plexus, which is particularly
manifest when the vessel is inflamed. The
veins follow the  course of the arteries,
and  according to Mascagni and  others,
lymphatic vessels also exist as a constitu-
ent part of the coats of the blood-vessels.
  The arteries are likewise supplied with
nerves.  These  are  derived, for the most
part, from the ganglionic system, and are
particularly abundant within the splanch-
nic cavities, where they twine around the
vessels, and form an intricate plexus. The
filaments of these nerves also twine upon
the  tunics  of the  arteries beyond  the
mere vicinity of their origin, and  can be
traced following them  far into the  sub-
stance of the organs.  It is indeed highly
probable, Jthat they accompany the blood-
vessels to their terminations, and exercise
an important control  over the acts  of  cir-
culation, nutrition, secretion, exhalation,
&c, in all of which acts, the vessels are
directly concerned. They have been traced
even into the bones of the extremities,
following accurately the course of the ar-
teries, and  terminating with them upon
the delicate medullary  membrane.  Tie-
demann, moreover, found them very large
upon  the  arteries  of the  penis  of  the
horse.  The arteries receive, besides,  fila-
ments from the cerebro-spinal nerves, and
these, as well as the ganglionic, are  dis-
tributed to both the cellular and fibrous
tunics.
   5 4.  Properties of the Arteries.  One
of the most remarkable properties of the
arteries is their  elasticity.  This they pos-
sess in a high  degree, in both the trans-
verse  and longitudinal  direction, but it is
always greatest in the latter. Hence they
admit of a greater degree of distension in
the  direction of their length, than trans-
versely ; from which circumstance, it has
been inferred by many physiologists,  that
during each systole of the heart, the arte-
ries become considerably elongated, while
their distension  in the  opposite direction
is comparatively trifling.  This distension,
however, can only take place to a limited
extent, without  a rupture of the  two in-
ternal tunics, which, on account of their
fragility, yield very readily, and thus give
rise  to  aneurism.   It  has  indeed  been
affirmed by Wintringham (Experimental
Inquiry,  p. 182.), that the  power of re-
sistance possessed by the arteries  is infe-
rior to that of the  veins, although  the
coats  of the  former are  much thicker.
The justice  of this inference  has  been
called in question by Gordon.  (Anatomy.
I.  57, 58.)   He  performed  several ex-
periments by suspending weights  to dif-
ferent arteries.  The carotid ofa man sus-
tained  30 pounds weight before  it gave
way:  one  of the  iliacs  sustained 48
pounds;  and a transverse  section of the
carotid used in the first experiment, only
three-fourths of an  inch  long, and one-
eighth of an inch in breadth, was capable
of sustaining 5 pounds.  He also found,
that air  forced into the aorta, with suffi-
cient energy to rupture its  coats, required
to be propelled with an impetus equal to
one  hundred  and  nine pounds.   It has
been supposed that  elasticity is predomi-
nant in the large arteries, and contractility
in the smaller ramifications.
   Do the arteries possess irritability 1 and
are  they endowed with contractility, in-
dependent  of that  which  they  derive
from mere  elasticity1?  This has  been
affirmed  and denied,  by  different physi-
ologists.  The negative has been advo-
cated by Haller, Bichat, Nysten, Ma-
gendie,  and many other modern physiolo-
gists.  The principal  arguments  which
have been invoked  in support of this side
of the question are,—that mechanical and
chemical irritants  occasion  no manifest
contraction in an artery when applied di-
rectly to it; that when it is laid open and
stimulated, it does  not contract, so  as  to
evert its edges, as is done  by a portion of
intestine under the same  circumstances;
that no  contraction takes place when it is
 separated from the heart, as, for example,
 where  a portion of the vessel is included
 in a ligature; that neither the direct irri-
 tation of a nerve leading to an artery, nor
 the influence of galvanism, gives rise to
 this phenomenon; and, finally, that opium,
 the tendency of which is to extinguish
 the mobility of parts endowed with irrita-
 bility, exercises no influence over that  of
 the arteries.
   These arguments,  together with many
 more which have been urged by Bichat
 and others who maintain a similar opinion,
 are not allowed by their opponents to be
 valid, and most of them are positively con-
 tradicted by experiment   Hence,  Van
 Doeverin, Zimmerman, Verschuir, Hun-
 ter, Soemmering,  Hastings, Thomson,
 Sir Everard Home, and indeed a majority
 of modern  physiologists, have maintained
 that the arteries are both  irritable and
 contractile.  In opposition to the  first ob-
jection  urged by Bichat, it has been al-
 leged, that although  the  arteries do not
 always contract on the application of me-
 chanical or chemical stimuli, this effect is
 frequently induced.  Verschuir, Zimmer- 
312
ARTERIES.  (Gen. Anat.)
man,  and Lorry, saw  manifest  contrac-
tions  induced by the application of mineral
acids; Thomson, under the irritation pro-
duced by the point ofa needle, and by the
volatile alkali;  and Wilson Philip, by
the rays of the sun, by gentle friction, and
by alcohol: Verschuir  also produced con-
tractions of the arteries  by irritating them
with the point of a scalpel;  and  in twen-
ty-five experiments performed by Hast-
ings  on  the different arteries of horses,
dogs,  cats, and  rabbits, with simple me-
chanical irritation,  ammonia, nitric  acid,
and the influence of atmospheric  air, con-
traction and increased  action ensued in
all. (An experimental Inquiry on Inflam-
mation, &c. 29. 1821.)   Bichat  was also
wrong in asserting that the  arteries do
not contract under the influence  of  elec-
tricity and galvanism. In the experiments
of Bikker, Van den  Bosch, and  Van
Geuns,  the electric spark excited mani-
fest contractions; and the same effect was
produced  by galvanism,  in the  experi-
ments of Giulio and Rossi.  That these
agents do not always produce contractions
in the arteries, should not excite surprise,
because the heart and many muscular or-
gans  of the involuntary character, which
are irritable in a high degree, frequently
resist their  influence.   Irritation applied
to the nerves which lead to an artery will
sometimes  occasion it to  contract.  This
is proved by the experiment of Sir Ever-
ard Home,  in which the application  of
caustic potash to the sympathetic nerve
of a rabbit, caused the carotid arteries to
beat rapidly for some time.
  It has been  satisfactorily demonstrated,
moreover, that the contractions of the ar-
teries take place independently of the
heart.  Thus, the circulation has  been re-
peatedly seen continuing for some  time
in animals after the removal of the heart,
or where  all its influence had been cut
off, by the application of a ligature to the
aorta.  During the first periods  of fiEtal
existence,  throughout the entire uterine
life of many acephalous monsters, and in
some  animals,  the  circulation is carried
on perfectly,  although  no  heart exists;
and in many state's  of the system, as, for
example, in cases of local inflammation,
the arteries pulsate violently in the in-
flamed part, although in other situations
their action is undisturbed.
  All these facts prove incontestably, that
the arteries are endowed with contractd-
ity, and render it probable, that they also
possess  irritability.   It does not follow
from  this admission, that  in  this respect
they  are identical  with muscular fibre.
There may be a similarity  of action  in
 two tissues, without this being adequate
 to prove that there is an identity of struc-
 ture, or of vital endowment.   The  con-
 tractility of the arteries, therefore, is pro-
 bably very different fron that of muscles,
 —and this has  induced Parry, and some
 others, to call it tonicity.
   The arteries do not manifest much sen-
 sibility in their healthy state;  but when
 they take on  inflammation,  they some-
 times become acutely sensitive. Perform-
 ing, as they do, the  important office of
 conveying the  blood  to all parts of the
 body, their plastic  forces are very strongly
 developed, and their powers of reproduc-
 tion are possessed  of great activity. Their
 extensive  anastomosis  is  not  the  only
 means with which  they are  provided  to
 compensate for any injury or accident they
 may sustain;—they are also endowed with
 the  capability of generating new vessels.
   In the performance of their office of cir-
 culating the blood, the  arteries  present a
 phenomenon which is denominated the
 arterial pulse. Some difference of opinion
 exists relative to the cause of this pulsa-
 tion ; some attributing it to the dilatation
 and contraction of  the artery,  while by
 others it is supposed that the  artery  is
 passive,  and the pulsation  is owing alto-
 gether to the impulse of the heart.  It was
 long since remarked by Haller, that the
 dilatation of the artery, during its pulsa-
 tion, cannot be perceived  by the finger,
 but  can only be  inferred.  Bichat has
 adopted the same view, and attributed the
 phenomenon of the pulse to a kind of lo-
 comotion of the artery, consisting princi-
 pally in its elongation under the influence
 of the impulse imparted to the column of
 blood, by the contraction of the  ventricle.
 Parry has, moreover, instituted  a number
 of experiments  on living  animals, with
 the view of settling the question, and he
 declares, as  the  result of  experiments
 made on  fifty-five of the larger arteries
 of horses, sheep, and dogs, that  he could
 not  discover,  in a  single instance,  the
 smallest  dilatation or contraction  corre-
 sponding with the systole or diastole of
 the heart  Results of so opposite a char-
 acter have been obtained by a majority of
 physiologists, both anterior and subsequent
 to the period  at which Parry  made his
 investigations, that we may regard his in-
 ferences as completely controverted. The
 dilatation and contraction of the arteries
 have been  demonstrated to possess so di-
 rect a connexion with the pulsation of the
artery, that the question so long mooted
may be  regarded  as definitively settled.
The experiments  of  Poiseuille, espe-
cially, who has invented an instrument of 
                            ARTERIES.

exceeding delicacy to measure the degree
to which these changes take  place,  are
conclusive upon this point  (Repertoire
Genirale d'Anatomie, &c. VI. VU.   Pa-
ris, 1829.)  If,  indeed,  these facts were
not sufficient to disprove the conclusions
of Parry, a satisfactory refutation of them
is furnished  by various  states of the  cir-
culation ; as, for example, the want of har-
mony, as regards time between the pulsa-
tion of different arteries, and between the
arteries  and the systole of the ventricle;
the increased pulsations of the vessels in
an inflamed part, while the other arteries
experience no change in their action; and
various other  phenomena which will  be
described  elsewhere.  (See  Circulation,
and Pulse.)
   From  what has been  remarked,  the
pulsation of the arteries cannot with pro-
priety be referred  exclusively to any one
of the conditions  which have  been enu-
merated, but is owing to the joint opera-
tion of all of them.  The impulse  of the
ventricle,  and the locomotion of the ar-
tery occasioned by its elongation, mani-
festly  perform the most important part;
but the dilatation  and contraction of the
artery also contribute something, and it is
hence proved, contrary to the sentiment
of many  physiologists,  that  the arteries
have   a  more important  agency in  the
circulation of the  blood,  than the  mere
influence of their elasticity.
   There are no animal structures which
are more extensively influenced by  age
than the arteries.   In young subjects, they
are abundant  and remarkably large, in
proportion to  the  volume of the  parts
which they supply.  They are also much
softer, and more pliant and elastic than at
a later period.   As age advances, they be-
come  more  compact rigid,  and fragile;
some  parts of  them, as, for example, the
arch of the  aorta, become dilated and at-
tenuated, and  the whole  arterial system
loses  much of its  elasticity.   Those ves-
sels which are most dilated,  frequently
become  divested  of every indication  of
this property.   In  advanced life,  their tu-
nics, in a majority of individuals, undergo
extensive calcareous or osseous transform-
ations, and are also often the seat ofa spe-
cies of atheromatous degeneration, which
has been particularly noted by Scarpa, as
constituting the principal source  of aneu-
risms.  This earthy deposit is not formed
in the lining membrane of the arteries, as
represented by Meckel and a majority of
pathologists, but in  the delicate substra-
tum of cellular tissue which unites it with
the fibrous tunic. (See Path. Anatomy of
the Arteries.)
   vol. n.          27
(Gen. Anat.)                        Jld

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 schaftlichen Annalen.   Marz. 1834.


   Art. II.  Arteries.  Special Anatomy.
 The Aorta (Arteria Aorta)   (Fig.  1. b.
 Fig. 14. b,  b.) forms the great trunk of
 the  arterial system, through which the
 blood is sent from the left ventricle of the
 heart, to all parts of  the body. From near
 the centre of the base of the  left ventricle
 of the heart, it proceeds upwards, slightly
 forwards, and a  little inclined towards the
 right side, placed at  its origin, behind the
 root of the pulmonary artery (Fig. 1. c),
 by which it  is concealed to the extent of
 a few lines, and in front of the left  auri-
 cle.   Thus ascending in the direction of
 the  axis of the ventricle, and behind the
 sternum, from  which it is  merely sepa-
 rated above by the  cellular  tissue which
 occupies the  anterior  mediastinum,  it
 reaches the level of the anterior extrem-
ity of the  third  rib, and  there changing
its direction, sweeps across the  anterior
face of the Becond and third dorsal verte-
bra,  and in front of the trachea just above
where  it divides into the right  and left
bronchi, thus forming a regular arch (Fig.
1. 6.) extending from right to left, and

                  Fig.l.
 a, Pericardium,  6, Arch of Aorta,  e. Pulmonary Artery,  d,
Innominata.  e, Left Carotid. /, Left Subclavian, g, Right Caro-
tid. A, R ght Subclavian.
with a slight inclination from before back-
wards.   The aorta  having reached  the
left side of the  third dorsal vertebra, the
arch is there terminated, and  the vessel
descends thence  in  nearly a perpendicu-
lar direction (Fig. 14.  6, 6.), in  the pos-
terior  mediastinum, along the  left side
of the bodies of the dorsal vertebra, co-
vered  on the left side  by the left pleura,
and  having on its right, the oesophagus,
the vena azygos, and the  thoracic duct
It then passes between  the pillars of the
diaphragm,  through the  hiatus aorticus,
enters the abdomen, and continues its de-
scent upon the bodies of the vertebra, un-
til it reaches the level of the articulation
between the fourth and fifth lumbar ver-
tebra,  where  it  terminates  by  dividing
into the two primitive iliacs (Fig. 17. e.),
which supply the inferior extremities and
the pelvis.
   The aorta has been divided into ascend-
ing, transverse,  and descending portions:
the first including the  course of the ves-
sel from its origin to the commencement
of the  arch; the second  the arch itself;
and the third all that portion between the
termination of the arch, or the third dorsal 
ARTERIES.  (Special Anat.)
315
vertebra, and the point at which it termi-
nates in the iliacs.  It is also divided into
thoracic (aorta  thoracica) and  abdominal
(aorta abdominalis) aorta.
  At its origin, the coats of the aorta are
very thin, and have no direct  continuity
with  the muscular structure of the ven-
tricle. This latter  merely overlaps the
surface of the root of the vessel to a lim-
ited  extent, and adheres very  slightly
with  it.    The  principal  attachment is
formed by an adhesion which is establish-
ed between the thin margin of the fibrous
coat  of the aorta, and  a band of elastic
fibrous tissue which  surrounds the orifice
of the ventricle,  and by the lining mem-
brane, which continues from the ventricle
into the artery, and is folded upon itself to
form three semilunar valves  with free
margins (Fig. 14. a.), which, when they
are elevated from the sides of the vessel,
accurately close its  orifice.  The portion
of the aorta which corresponds to the situ-
ation of these valves is not perfectly cylin-
drical, but  is rendered somewhat  triangu-
lar, by three slight bulgings of its tunics,
which form what are called the lesser si-
nuses of the aorta, or sinuses of Valsalva.
These are natural, and are not a patholo-
gical state  of the vessel,  arising from a
distension of its  tunics occasioned by the
impulse  of the blood.
  At its origin, the aorta  is contained
within the pericardium  (Fig. 1. a.), and
is overlapped by the pulmonary artery (c),
which is in front of it—and slightly by
the right auricle.  At about two inches or
two inches and a quarter from the ventri-
cle, it escapes  from that sac,  and as it
ascends, has the trunk of the pulmonary
artery on the left side,—the right branch
of that vessel behind, the descending cava
and the  right lung on the right, and  the
sternum  in front.
  The transverse  portion is in relation
anteriorly with the  sternum, from which
it is  merely separated by the mediastinal
cellular tissue, and is crossed above by  the
vena innominata or left brachio-cephalic
vein, which overlaps it  The concave face
of the arch sweeps over  the bifurcation
of the pulmonary artery, with which it is
connected  by the remains of the ductus
arteriosus; and posteriorly, the aorta  re-
poses on the anterior face of the trachea
a little above its bifurcation,—and towards
the  left  side, arching over the left bron-
chus and the left branch of the pulmonary
artery, it descends behind them, and takes
its course along the  left side of the bodies
of the dorsal vertebra.  The left pneumo-
gastric  nerve  descends in  front of  the
arch,  and, on a  level with  its concave
face,  gives off the left recurrent  nerve,
which, passing backwards and upwards,
hooks round the  aorta and ascends upon
its posterior face.
  The aorta usually gives off five branches,
between  the  point at which it leaves the
ventricle and the termination of the arch,
viz. the coronary arteries, two in number,
which come off near the  heart, and sup-
ply that organ; the innominata or brachio-
cephalic, the left carotid (Fig. 1. e.),  and
the left subclavian (Fig. 1. f).   These
three vessels  proceed directly from  the
convexity of the  arch, and supply  the
head, neck, upper extremities, and  the
upper part of the  thorax.
  The coronary or cardiac arteries (a. co-
ronoria, s. cardiaca) are generally two in
number,  rarely three (Winslow,  Meck-
el),  which are  denominated right  and
left,  from the order of their distribution.
  A.  The  right coronary artery (a. coro-
naria, s. cardiaca dextra, s. anterior, s.
inferior)  is generally  somewhat  larger
than  the  left, though in some rare in-
stances it is smaller. It arises from the an-
terior part of the root of the aorta, a little
to the right and immediately above the
anterior semilunar valve, but so high as
not to have its orifice closed by this last.
Taking its course towards the  right side
of the heart, it passes behind the  root of
the pulmonary artery, following the course
of the fissure between the right ventricle
and  auricle, and after giving off  several
small ramuli, which pass  off at right an-
gles, to the pulmonary artery, the root of
the aorta, the right auricle and vena cava,
as well as to the  fat about the base of the
heart and the base of the right ventricle,
it divides into three branches, which may
be denominated inferior, superior, and pos-
terior.
   a. The inferior branch (ramus inferior)
takes its course downwards and forwards,
and  winds in a  tortuous direction along
the thin margin  of the heart sending off
ramuli on each side  to the substance of
the  ventricle, and finally terminating at
the  apex of the  heart by  anastomosing
freely with the posterior branch, and with
the branches of the left coronary.
   There  is generally a  smaller  inferior
branch, which comes off higher up,  and
descends in a perpendicular direction upon
the anterior face of the ventricle, anasto-
mosing on the one hand with the left co-
ronary artery, and on the other with the
proper inferior branch of the right.
   b. The superior branch (ramus supe-
rior,  s. circumflexus  coronaria  dextra) 
316                       ARTERIES.  (Special Anat.)
twines round the base of the heart, lodged
in the right auriculo-ventricular fissure,
until it reaches a similar branch from the
left coronary.  In this course, several ra-
muli are distributed upwards to the right
auricle, and downwards to the walls of
the corresponding ventricle.
  c. The posterior branch (ramus poste-
rior, s. septi ventriculorum posterior) de-
scends upon the  posterior  face of  the
heart,  following  accurately the groove
which corresponds to the posterior part of
the septum  of the ventricles, and  finally
terminates at the  apex of the ventricles,
by anastomosing with the inferior branch,
and with the left coronary.   In its course,
it sends  numerous ramuli to the walls of
the right and left  ventricles and the sep-
tum cordis.
  B.  Left  coronary or cardiac artery.
(A. coronaria, s. cardiaca sinistra, s. pos-
terior, s. superior.)  This artery is gene-
rally smaller than  the preceding,   and
takes its origin from the anterior left side
of the root of the aorta, two or three lines
higher up, above  the free margin of the
left semilunar valve.   It takes its course
towards the  left side of the heart, between
the aorta and pulmonary artery, and in
the fissure between the left ventricle  and
auricle, and is overlapped by the tip of
the latter.   After giving off small ramus-
culi to the  aorta,  the pulmonary artery,
left auricle  and left ventricle, it divides
into two principal branches,—one poste-
rior, which follows the auriculo-ventricu-
lar fissure; the other, anterior or descend-
ing, which follows the groove correspond-
ing to the septum  of the ventricles.
  a. The posterior or circumflex branch
(ramus posterior, s. circumflexus corona-
ria sinistra) twines round the base of the
heart, in the fissure between the left ven-
tricle and left auricle, sending numerous
ramuli to the muscular walls of both these
cavities, and terminates posteriorly by an-
astomosing  with the  terminal ramuli of
the circumflex branch of the  right coro-
nary artery.
  b. The anterior or descending branch
(ramus anterior, s. inferior, s. descendens)
descends in a tortuous direction upon the
anterior  face of the heart, following the
groove which corresponds to the anterior
part of the  septum of the ventricles.  It
distributes numerous ramuli in its course
to the right  and left ventricles, and to the
septum cordis, and having reached the
apex of the heart, terminates by anasto-
mosing with the right coronary. Near its
origin, this  branch generally  gives off* a
ramulus  which descends along the thick
margin of the  left ventricle,  and distri-
butes numerous ramifications upon its sur-
face.  The left coronary artery, and some-
times the aorta itself, also gives off a branch
to the septum  of the  ventricle,  through
which it ramifies to the apex of the heart.
  Varieties.  Thebesius saw only one co-
ronary artery coming from the aorta, which
divided into two branches. (Diss, de circ.
sang, in corde. Lugd. Bat. 1716.) Green
has reported a case of the same kind (Va-
rieties of the Arterial System.  Tab. 1.
Fig. 3.), and a  third  has been reported
by Thomson.  (Edinb. Med.  and Surg.
Journal, for April,  1835.  p.  288.   The
existence  of three coronary arteries  has
been  witnessed  by Winslow  (Exposi-
tion Anatomique.  Paris, 1732.  p. 366.),
and by Fiorati (Atti  della Academia di
Padoua. III. 58.  P. 1.).  Meckel, in one
case, observed four; but the two supernu-
merary vessels were small, and presented
the appearance  of branches of the coro-
nary arteries prematurely given off.  (Ma-
nuel dCAnat. II. 314.)  Barclay saw the
right coronary terminating before it reach-
ed the septum cordis, and the circumflex
branch of the left, unusually large, going
round to supply its place. (A Description
of the Arteries, &c.  p. 6. Edinb. 1812.)
  C.  Innominata or brachio-cephalic ar-
tery (Fig. 1. d.).   (Arteria innominata, s.
anonyma, s. brachio-cephalica.)  This is
the first,  and by far  the largest, of the
three branches given  off by the arch of
the aorta.  It  takes its origin  from  the
convexity of the arch, at the point of junc-
tion between the  ascending and trans-
verse  portion,  and on a level with  the
point of union of the cartilage of the sec-
ond rib with the sternum.  It mounts up-
wards and a little outwards,  behind  the •
sternum and the sterno-clavicular articu-
lation, and, at about an  inch  or an  inch
and a  quarter,  in some rare  instances
(Burns) two inches from  its origin, di-
vides into the right carotid (Fig. 1. g.)
and the right subclavian  (h.) arteries,  the
first of which supplies the  right side of
the head and face, while the second sends
its branches to the right upper extremity,
and to a part of the corresponding side of
the neck and the upper part of the tho-
rax.  It is situated somewhat further for-
ward than the other branches given off
from the arch, in consequence of the slight
obliquity of the latter from before  back-
wards, and from right to left.
   In  front  the innominata is separated
from the sternum by the sterno-thyroideus
and sterno-hyoideus muscles, and by the
vena innominata, or transverse  vein of 
ARTERIES.  (Special Anat.)
317
the neck, which crosses it in a transverse
direction. Its terminal portion is also situ-
ated directly behind the sterno-clavicular
articulation.  Behind, it reposes upon the
trachea, which  is slightly  to the left of it,
and between it and the vertebral column
are the longus colli muscle and the sym-
pathetic nerve.   On its right side, is  the
right brachio-cephalic vein, and on  the
left, the remains of the thymus gland.
Under ordinary circumstances, the inno-
minata gives off no branches between its
origin and where it divides into the right
carotid and  right subclavian; but  not  un-
frequently,  other branches, which gene-
rally take their origin elsewhere, proceed
from it
   The left  carotid arises from the con-
vexity of the arch of the aorta, immedi-
ately beyond the innominata, and near to
it Its course is upwards and slightly out-
wards, behind  the sternum, the left bra-
chio-cephalic vein, the sterno-thyroideus
and sterno-hyoideus muscles, and the  left
sterno-clavicular  articulation,  where it
emerges in the neck.   Posteriorly and in-
ternally, it is in relation with the trachea;
with which  it is in contact  The next in
order  is the left subclavian, which also
takes its origin singly from the arch, still
more profoundly than the preceding,  and
farther from the  median line.  It is very
deeply seated at  first,  and is covered for
some distance  from  its origin  by the tip
of the right lung, but ascending almost
perpendicularly to the level of the first
rib, it there  becomes more superficial, and
takes  its course  obliquely outwards over
the  surface of that bone.
  Varieties of the ascending aorta and its
arch. Departures of the aorta from the ar-
rangement described above, are not unfre-
quent A singular variety of this kind is one
described by Haller and Klint. The aorta
formed no arch, but  immediately after its
separation from the left ventricle, divided
into an ascending and a descending branch.
This distribution  is natural in  many ani-
mals.  (Tiedemann. Tab.  Art. tab. ii.  fig.
3.)  Hommel has described a  variety of
the aorta not less remarkable.   That ves-
sel divided at the commencement of the
arch, into an anterior and a posterior por-
tion, which, after passing a short distance,
again  united into a single trunk.   The
trachea  and oesophagus  pissed through
the  opening formed  by this arrangement
of the vessel. (Ibid.  tab. iv. fig. 6.)  Two
other examples of this  kind have been ob-
served,—one by  Malacarne,  the  other
by Bertin.  In  a case described by Mala-
carne, the  aorti, at its origin from  the
left  ventricle,  divided into two  great
                 27*
trunks, one situated upon the right, the
other on  the left  side.   In the mouth
of the vessel there were five  capacious
semilunar  valves,  and  each trunk,  as
it  ascended,  inclined inwards towards
its  fellow,  and  they united above,  to
form  the  descending aorta, which im-
mediately inclined  downwards, and pur-
sued its usual course.  From each of the
ascending  trunks,  three  branches  were
given off, the first of which was the sub-
clavian, the  second the  external carotid,
and the third the internal carotid.  (Ibid.
tab. iv. fig. 7.) Tiedemann has described
a very singular anomaly of the  aorta.   It
took its origin from the arterial portion of
the heart, by a trunk which was common
to it and  the pulmonary artery.  This
trunk, after ascending slightly,  gave ori-
gin, on the right side, to a large branch,
which ascended, and curved  outwards.
This branch furnished in succession, the
left carotid,  the  right carotid,  and right
subclavian.   The pulmonary arteries took
their origin from the posterior part of the
main trunk,  a little higher up,  and were
distributed as usual.  The trunk, a little
above this point, became very much con-
tracted, but immediately after resumed
nearly its  former calibre, curved down-
wards, and became the descending aorta.
From its  curve,  the left subclavian was
given off.  (Zeitsckrift fur Physiologie.
Bde. IV. h. 2.; and Lond. Med. Gazette,
II. 704. 1834.)
  A variation from the natural type  of the
arterial system, somewhat different from
either of those described, is that in which
the aorta takes its origin from the right
ventricle of the heart, and the pulmonary
artery from  the left. Cases presenting
modifications of this condition  have been
described  by Baillie, Farre, Langstaff,
Wistar,  Bock,  Fleischmann, Meckel,
Tiedemann,  D'Alton, Burkart, Duges,
and  Jacobson.  In the case reported by
Jacobson, the septum of the ventricles was
perforated by a small opening situated im-
mediately below the origin of the aorta, and
the pulmonary artery was preternaturally
small, the bronchial arteries being at the
same time very much dilated. (Meckel's
Archives fur Physiologie. II.  134.)  In
Wistar's  case, the ductus arteriosus was
closed.
  Sometimes the aorta arises directly over
the interventricular septum,  so as to com-
municate with both those cavities.
  In some instances, the aorta passes over
the right  bronchus.  (Meckel.)   It  occa-
sionally passes behind the  trachea and
cesophagus, to reach the  left side (Aber-
nethy, Elinkosch, Fiorati, Sandifort, 
318                      ARTERIES.  (Special Anat.)
Obet, Legallois,  Rudolphi,  Breschet,
Otto, Caillot, Meckel) ; and instances
occur, in which it descends to the lower
part of the thorax on the right side of the
spine. (Meckel.) A still greater displace-
ment  is that  in which its direction be-
comes transposed,—the arch passing from
left to right
  Anomalies of the descending aorta. Be-
sides the anomalies in the position of the
descending aorta described above,  that
vessel sometimes divides higher up  than
usual, into the two primitive  iliacs, and
these latter, before  subdividing, have been
seen  communicating  by  a  transverse
branch. (Petsche, Meckel.)   Huber has
described  an  example, in which the tho-
racic aorta, on a level with the seventh
dorsal vertebra, sent an  accessory pulmo-
nary artery to the right lung.   A similar
case has been published  by Maugars, but
still more remarkable in its character. An
accessory pulmonary artery was given off
by  the abdominal  aorta, which took its
course upwards, perforated the diaphragm,
and after supplying the phrenic artery, di-
vided  into two branches, one of which
was distributed to the  lower part of each
lung.   In an analogous case, observed by
Meckel, a vessel four lines in diameter,
took its origin from the anterior left part
of the aorta,  about half an inch above
where  it traverses the diaphragm.  This
vessel  inclined  a little  to the left side,
then descended about half an inch, and
divided into two branches, which plunged
directly into the lower surface of the in-
ferior lobe of the left lung.  (Archives fur
Physiologie.  VI. 453. tab. iii.)
  Varieties of the  branches proceeding
from  the  arch of the aorta.  Anomalies
in the origin of the  branches from the
arch of the aorta are so numerous, as to
render it impracticable to specify particu-
lar examples.  The number of the branches
furnished by the arch may be  diminished
or increased, or the origin of one or more
of them may be misplaced.  The increase,
as has been remarked by Meckel, is more
frequent than the diminution.
  The most frequent mode of diminution
is that in which the innominata, besides
the right  carotid  and  right subclavian,
gives off the left carotid, which under such
circumstances, crosses obliquely in  front
of the lower part of the trachea.  Another
variety belonging  to  the same  class,  is
that in which the left carotid and subcla-
vian arise by a common trunk, like the in-
nominata. (Malacarne, in two instances;
Biumi, Tiedemann.) Tiedemann describes
a case in which the first branch was the
right carotid, the second a common trunk
for the left carotid and subclavian, while
the right subclavian originated from  the
descending thoracic  aorta, and mounted
obliquely upwards behind its ascending
portion, to reach its  point of destination.
(Tab. II.  fig. 6.)   Sometimes the  right
subclavian arises  singly from the arch of
the aorta,—the two  carotids and the  left
subclavian,  from  the innominata  (Za-
gorsky) ; and a case  is described in which
the right subclavian,  and right and  left
carotids, had a common origin, while  the
left subclavian and  left  vertebral  were
given off separately  by  the arch.  The
most  frequent mode  of multiplication is
that in  which the vertebral artery arises
from the arch. With this anomaly is often
associated the  origin  of the left carotid
from the innominata.  Next to this in fre-
quency, is the origin of  the inferior thy-
roid, or  an  accessory thyroid, from  the
arch.  This  anomaly, signalized by  Neu-
baur, we have often observed.  Sometimes
both vertebral arteries proceed from  the
aorta, and occasionally a thymic artery
has a similar  origin.  The  same is also
true of the internal mammary and the  su-
perior intercostal.  These anomalies may
be combined in various ways, or one or
more of them may coexist; but in no case
does the number of branches arising from
the arch exceed six.
  The anomalies in the situation of  the
origin of the three trunks which naturally
proceed  from  the  arch, may be referred
either to the  fusion of two or more  of
them  which should be separate; the  sepa-
ration of the innominata into two vessels,
as when  the  branches which it should
furnish arise separately from the arch, and
the transposition of one or more of them.
Some of these varieties  have been  de-
scribed  above.  Thus  the innominata is
sometimes situated on the left side.  The
right  subclavian  may come off between
the right and left carotid;  it may  arise
between the left carotid and the left sub-
clavian, or it may be the last branch pro-
ceeding from the aroh. In either of these
cases, it generally crosses  the neck  be-
tween the  trachea  and  oesophagus,   to
reach the right side.   Sometimes, indeed,
it arises from the descending aorta, and
ranges  obliquely  upwards  towards  the
right side, behind the right bronchus and
the ascending aorta. (Tiedemann, Green.)
In some instances, on the contrary,  the
left subclavian arises on the right side,
and is the first branch furnished by  the
arch.   In other cases, the left carotid is
the first branch, the right carotid the sec-
ond, and the two subclavians the last
Slighter degrees  of anomaly consist in 
ARTERIES.  (Special Anat.)
319
the near approach or removal of the ori-
gin of the several vessels, to or from each
other.
  These are the  most important anoma-
lies which take place  at the arch.  They
sometimes, however, present combinations,
which it would require too much space to
describe in this place.  It is worthy of re-
mark, that many of these anomalies repre-
sent the natural type of the arterial sys-
tem in some  animals. (See Tiedemann.
Tab. Arteriarum.  tab. ii. iii. iv.   Carls-
ruhte, 1822.)
                  Fig. 2.
 o. Common Carotid. 4, Division of the Common Carotid, c,
External Carotid,  d, Superior Thyroid,  e. Lingual.  /, Facial.
f. Occipital.  A, Posterior Auricular,  t, Superficial Temporal, ft,
Transversalis Faciei.  /, Internal Carotid,  m, Right Subclavian.
n. Inferior Thyroid-  o. Ascending Cervical-  j>, Superficial Cer-
vical,  q, Superficial Scapular,  r, Transversal's Colli,  j, t, Axil-
lary Artery,  u, Tboracico Acromialis. v, Thoracieus Supremis.
to, Thoracieus Longua.  x, Subscapularis.  z, Occipital.

  D. The common  or  primitive  carotid
arteries (Fig. 1. e, g.  Fig. 2. a.) (arteria
carotides communes s. primiliva) present
some difference on the right and the left
sides.   The right arises from the innomi-
nata, as previously  stated; the  left  from
the  arch  of the aorta.   The former  is,
therefore, somewhat shorter,  more super-
ficial,  and a  little  more  oblique in  its
course,  than  the latter, which is deep-
seated at its origin, and ascends more per-
pendicularly.   In other respects, the de-
scription of one will apply to the other.
  The  common  carotid artery ascends
from its origin, by the side of the trachea
and  larynx, and  in  front of the roots of
the  transverse processes of  the cervical
vertebra; but in consequence of the artery
on the  right and that on the  left  side,
gradually receding from  each  other as
they advance upwards, they are  farther
separated above than they are below.  It
likewise presents  the  appearance of ad-
vancing backwards, or, as it were, retreat-
ing, so as to become more profound in the
upper  than in the lower part of the neck.
But this is in reality not the case;  the ap-
pearance  in question merely results from
the great projection forwards of  the la-
rynx and os hyoides in the upper  part of
the cervical region.  The artery,  indeed,
follows the  anterior face of the vertebral
column, until it reaches the level of the
superior margin of the thyroid cartilage,
or the space  between  it and the horn of
the os hyoides (Fig. 2. 6.), where it di-
vides into the internal and external  caro-
tid  arteries;—the  first of which  is  des-
tined to supply a part of the brain and the
eye, while the second is distributed to the
superficial parts of the neck,  facej and
head.  Between its origin and the point at
which it divides, the common carotid gives
oft' no  branches, except some very  minute
ramusculi which are seldom apparent.
  The carotid  is  covered  in the lower
part of the neck,  by the skin,  platysma
myoides, and cervical  fascia, the  sterno-
cleido-mastoideus,   sterno-hyoideus,   and
sterno-thyroideus muscles. Near the level
of the inferior margin of the cricoid car-
tilage, it is crossed obliquely by  the  omo-
hyoideus, and in the  upper part of the
neck, the descending branch of  the ninth
pair of nerves courses  along upon  the an-
terior  part of its  sheath,—sometimes, in-
deed,  contained within it.  In this latter
situation, in  consequence of the inclina-
tion of the sterno-cleido-mastoideus mus-
cle backwards, the artery  is no longer
covered by it but is  placed directly be-
neath  the  skin,  platysma myoides, and
cervical fascia, and can consequently be
much  easier reached  above the point at
which it  is crossed by the omohyoideus,
than lower down.
   Internally, the common carotid is in re-
lation  with  the trachea, the thyroid gland,
which generally overlaps it, and  the la-
rynx ; and on the left side, likewise with
the oesophagus, in consequence of  the in-
clination  of that  tube to the left of the
median  line.  When  both  carotids are
given off by the  innominata, they gene-
rally run, near their origin, obliquely upon
the lower part of the  trachea, especially
the right, so that in the operation of bron-
chotomy,  the artery might be wounded in
attempting  to open that tube.   The left
carotid is, besides, crossed near its origin
by the left brachiocephalic vein.  Poste-
riorly, the  artery  is in relation with the 
320
ARTERIES.  (Special Anat.)
spine, from which it  is separated by the
longus colli, and the rectus capitis anticus
major muscle.  There are, moreover, in-
terposed between it and the vertebral col-
umn, in the lower part of the neck, the
recurrent  nerve and  the  inferior thyroid
artery;  and on the left side, besides these,
the thoracic duct:—throughout the whole
extent of the artery,  the  cervical portion
of the great sympathetic nerve is directly
behind the vessel, but is  not included in
the same sheath.  Externally, the internal
jugular vein runs parallel  with the artery,
and  when distended,  overlaps  it   The
pneumogastric  nerve  also courses  along
its  outer  side, but is somewhat deeper
seated, and is contained in the posterior
portion  of the strong sheath,  which in-
vests it, in common with the artery and
the jugular vein.
  E.  External carotid artery.  (Ramus
carotis  externus, s. cephalicus externus.)
(Fig. 2. c.)  This branch, which is  dis-
tributed to a part of the neck, to the face,
and the superficial parts of the head, is, in
the foetus, where the  brain  is relatively
very voluminous, much smaller than the
internal carotid; but in the adult it equals
that vessel in size, and in some instances
is even larger.   At the  point at  which
the common carotid  bifurcates, the  two
branches repose in contact; but as the in-
ternal forms a slight convexity forwards
at its origin,  it is generally most superfi-
cial at  first  but  after ascending a small
distance, becomes deeper  seated than the
other.  The external carotid advances up-
wards and a little backwards, becoming
at the same time somewhat deeper, from
the level of the upper margin of the thy-
roid cartilage, passing first  beneath the
hypoglossal nerve, and the stylo-hyoid and
disgastric muscle,—then through the sub-
stance of the parotid gland between the
angle of the jaw and the  ear, until  it
reaches the  vicinity  of the  neck  of the
inferior maxillary bone, where it divides
into two branches,—the internal maxillary
(Fig. 5. a.),- and the temporal (Fig. 2. i.).
   In the first part of this course it is su-
perficial,  and is merely  covered by the
skin, platysma myoides, and cervical fas-
cia: higher up  it is  crossed in front by
the hypoglossal nerve, the stylo-hyoideus,
and the posterior belly of the digastricus;
and above this point, it plunges  into the
substance of the parotid  gland, in  which
it is still embedded where it divides.  In-
ternally, it is in relation with the pharyn-
geal  plexus  of nerves, the  stylo-glossus
and stylo-pharyngeus muscles, and the
glosso-pharyngeal nerve,  which separate
it from  the internal carotid.
  In its course, the external carotid gives
off  several branches, which may be di-
vided into anterior, internal, and posterior.
The anterior are, the superior thyroid, the
lingual, and the facial: internally, it fur-
nishes the ascending or inferior pharyn-
geal, and  posteriorly, the  occipital and
posterior auricular.
  a. The superior thyroid artery (Fig. 2.
d.) (ramulus thyroideus  superior) is the
first branch given  off by the external ca-
rotid artery.  It arises from the  anterior
part of that vessel near  the bifurcation,
and sometimes even from the common ca-
rotid.  It advances at first upwards and
forwards, then,  forming a curve, the con-
vexity of which is directed upwards and
towards the larynx or os hyoides, it takes
its course downwards and inwards towards
the  thyroid gland,  into the  upper portion
of which its numerous ramusculi plunge,
and  form an intricate anastomosis with
those of the corresponding  artery of the
opposite side, and  with those of the  infe-
rior thyroid.  In this course, the artery is
covered by the  skin, platysma, and cervi-
cal  fascia,—is accompanied by the supe-
rior laryngeal nerve, which is deeper seat-
ed, and furnishes the following ramusculi:
  a. R. hyoideus, s. sterno-cleido-mastoi-
deus.  This is generally a small branch,
which is given off near the origin of the
artery, and which immediately divides into
two ramifications.  The first takes its
course directly forwards,  below  the  horn
of the os hyoides, to anastomose with a
similar vessel  of the opposite side, and to
send minute ramifications into the thyro-
hyoid ligament, to the muscle of the same
name, and to  the other  adjacent struc-
tures.   The other winds its way down-
wards and outwards  across the  front of
the common carotid artery, and is princi-
pally spent upon the sterno-cleido-mastoi-
deus muscle.  This ramification  is gene-
rally divided in exposing the carotid ar-
tery to apply a ligature.
  (3. R. laryngaus.  This  branch some-
times comes off in common with the pre-
ceding, and in  some instances even from
the  common carotid.   It  advances  for-
wards and inwards, in company with the
superior laryngeal  nerve,  sends  small
branches to the thyro-hyoid and omo-hyoid
muscles, and  having reached the  upper
part of the larynx, penetrates ordinarily
above the margin  of the thyroid cartilage,
and between it and the horn of the os hy-
oides, by perforating the broad thyro-hyoid
ligament,—sometimes through a special
opening in the thyroid cartilage itself, and
more rarely through  the  ligament which
fills up the space between the thyroid and 
ARTERIES.  (Special Anat.)                      321
cricoid cartilages.   When this latter dis-
tribution exists, it anastomoses  with  a
similar  branch from  the opposite  side,
upon the surface of the ligament, where,
being superficially situated, it may be di-
vided in the operation of laryngotomy;
and even in those  cases in which the ar-
tery enters the larynx at the first or sec-
ond points, it generally sends off a small
crico-thyroid branch, which traverses the
same  ligament.  The  terminal ramifica-
tions of the laryngeal branch,  are distri-
buted to the mucous membrane, the upper
part of the epiglottis, and to  the  small
muscles  of the larynx.  One sometimes
passes  outwards  to  the thyro-hyoideus
muscle.
  b. Lingual Ar-        Fig- **•
tery.   (Fig. 2.  e.
Fig. 3. a.)   (Ra-
mulus lingualis.)
This branch, which
is sometimes larg-
er  than  the  last
described, takes its
origin from the an-
terior part of the
external   carotid
(Fig. 3. d.), a little
higher   up,   and
somewhat   more
profoundly. It ad-
vances  forwards, £ Do"rsaiu*Ling"u'»5r
inwards, and a little  upwards, above the
horn of the os hyoides, and below the hy-
poglossal nerve, with which it runs paral-
lel. It there glides between the hyoglossus
muscle and the middle constrictor of the
pharynx,  changes  its direction,  and as-
cends  in  nearly a perpendicular course,
until  it  becomes  fairly  engaged in the
tongue, where  it again resumes the hori-
zontal direction, and advances forwards
under the name of the ranine  artery, along
the lower surface of the tongue,  between
the genio-glossus and lingualis, accompa-
nied by the lingual nerve, and finally ter-
minates at the tip of that organ,  by  anas-
tomosing in form of an arch with the cor-
responding branch of the opposite side.
  In this course, the lingual artery  gives
off several branches:  1. Small ramus-
culi to the hyo-glossus, the  middle con-
strictor, and the submaxillary  gland.   2.
The hyoid branch (ramus hyoideus), which
comes off behind the hyo-glossus muscle,
and descending downwards  and  inwards
between the genio-glossus and genio-hyo-
ideus,  distributes  ramifications  to  these
muscles, and terminates at the os hyoides,
by  anastomosing with the branch of the
opposite  side.   3.  From one to three or
four small branches (ramuli  dorsales lin-
 a, Lingual Artery,  o, Ranine.
e. Sublingual,  d, External Carotid,
gua. Fig. 3. e.)  from tbe ascending  or
perpendicular portion of the artery, which
advance  towards the root  of the tongue,
beneath  the  hyoglossus muscle,  sending
ramifications to it, to the  epiglottis, ton-
sils, and  palate.   4. The  lingual artery
beyond this point divides into the ranine
(Fig. 3.  b.)  and sublingual  (Fig. 3.  c.)
branches,  the  first of which is distri-
buted  along  the  lower surface  of  the
tongue, as far as  its tip, being merely co-
vered  by  the  mucous membrane, and
placed immediately by the side of the fre-
num, where  it may be wounded in  di-
viding that band.   The second, or sublin-
gual, which is sometimes furnished by the
submental branch of the facial, is situated
further outwards.  It advances  horizon-
tally forwards, between the genio-hyoi-
deus and  the sublingual  gland,  sending
numerous ramifications to both, and finally
perforates  the mylo-hyoideus muscle, and
is expended  upon it and the digastricus,
forming  at the same time a free anasto-
mosis  with the submental branch of the
facial.
   From  these various sources, the tongue
receives  an  abundant supply of vessels,
which ramify minutely through  its sub-
stance, and anastomose with those of the
opposite  side.
   c. Facial,  or External  Maxillary Ar-
tery.  (Figs. 2, 4, 5. /) (Ramulus faci-
alis, s. maxillaris externus.  Palato-labi-
ale, Chauss.)  This branch takes its ori-
gin from the carotid, higher than the lin-
gual, and is frequently somewhat larger
than that vessel, though in many instances
it is smaller, and does not reach the whole
of its points of destination.  In such cases,
the parts of  the  face which are  not sup-
plied by it,  receive branches from  the
transverse facial.   The course of the fa-
cial artery is at first upwards and slightly
forwards,  along  the side  of the pharynx,
and beneath the stylo-hyoideus  and the
posterior belly of the digastricus  muscles.
Having reached this point it plunges  be-
neath the submaxillary gland,  becomes
profoundly embedded between that body
and the  inferior part of the lower jaw
bone,  and from  thence glides obliquely
outwards,  along the upper surface of the.
gland, and  beneath the  margin of the
bone, over the surface of which it twines,
to mount upon the face, where it  is super-
ficial, and can be easily felt pulsating upon
the surface of the inferior maxillary bone,
and immediately in  front  of the  edge of
the masseter muscle.  From this  situa-
tion, it glides obliquely upwards  and for-
wards, reposing  for some distance upon
the buccinator muscle, and having reached 
322                       ARTERIES. (Special Anat.)
the angle  of the  mouth, passes beneath
the lower part of the zygomatic, and  le-
vator muscle of the angle of the mouth,
ascends by the side of the nose, and after
sending numerous ramusculi to the vari-
ous parts situated in its course, terminates
near the inner angle of the  eye, by form-
ing a free anastomosis with the branches
of the ophthalmic artery.
  The branches given off in  this transit
of the facial artery, may be divided into
two orders:—those which proceed  from
the vessel before it twines over the sur-
face of the jaw, and those which  arise
from it while pursuing its tortuous course
along the face.
  a. R. palatinus inferior, s. adscendens.
This  branch  not unfrequently comes off
from the inferior pharyngeal, or even the
carotid.  It usually arises from the facial,
a few lines from the external carotid, and
mounts upwards between the stylo-pha-
ryngeus  and stylo-glossus muscles, send-
ing off small  ramusculi  in  its course  to
the pharynx and adjacent parts, and is dis-
tributed  to the  tonsds, eustachian  tube,
and soft  palate.   There  is one  small ra-
musculus especially, which,  separating
from the rest near the levator palati mol-
lis, follows the course of the circumflexus
palati, ramifying extensively in the velum
of the palate  and the uvula,  and anasto-
mosing freely with a similar branch  from
the opposite side.
  (3. R. musculares, variable  in  number
and size, are distributed to the disgastric,
styloid,  and pterygoid muscles; some  of
them are  likewise  expended upon the
pharynx.
  y. The r. tonsillaris is a  small branch,
which ascends in the vicinity of the sty-
lo-glossus muscle near its termination, and
distributes its ramifications  to the tonsil,
and the adjacent portion  of the same side
of the tongue.
  8. R. glandulares are  four or five small
branches which  plunge directly into the
submaxillary gland  and  ramify through
its substance, most of them terminating
in its granular structure,  while a few ex-
tend to the adjacent muscles.
  t.  R.  submentalis  (Fig.  4. b.) is an
important branch of the  facial.  It  usu-
ally arises from that vessel where  it  is
about to  emerge from between the lower
jaw and the submaxillary gland.  Taking
its course forwards,  it glides along the
6urfa.ce of the mylo-hyoid muscle, nearly
in contact with  the internal part of the
lower margin  of the jaw, and above the
anterior  belly of the digastric  muscle.
Having arrived  near the chin,  it  usu-
ally  divides  into two branches, one  of
which sends ramifications into the digas-
tric, mylo-hyoideus, genio-hyoideus,  and
genio-glossus  muscles,  and  anastomoses
with  the  ramifications from  the opposite
side,  as well  as with the hyoid  branch
of the lingual artery.  The other mounts
upon  the chin (b.), anastomoses with  a
small branch of the inferior dental which
escapes from the bone through the  mental
foramen, and after ramifying minutely in
the integuments and muscles of the chin
and lower lip, ends by anastomosing ex-
tensively with the ramifications of the in-
ferior labial or coronary.   In this course,
the submental ramusculus sends ramifica-
tions to the submaxillary gland, to the ad-
jacent muscles,  and to several lymphatic
glands which repose in contact with it It
also, in some instances, where the lingual
artery is small, supplies the ranine branch
to the  tongue.
  The branches sent off by the  facial,
after it has ascended above the margin of
the lower jaw, are,
  £. R. masseteres (Fig. 4. a.), consist-
ing of one or more small branches which
come off posteriorly, where the artery is
coursing over  the surface of the bone,
and, ascending upwards and backwards,
ramify in  the  masseter, buccinator, and
platysma  myoides  muscles,  and in  the
cellular tissue  and  fat  of the face,  the
parotid gland, and other adjacent  parte.
They  anastomose with the ramifications
of the temporal.
                 Fig- 4-
 a, Maseteres. b. Submental, d, Anterior Superficial Temporal.
/, Facial,  c Inferior Labial,  t Supra Orbital.

  •7. R. labialis inferior, vel superficialis.
This  ramusculus  usually arises  some-
what lower than the preceding, from the
anterior  part  of the  facial  artery,  and
sometimes from the inferior coronary.  It
advances  forwards,  and ramifies exien- 
ARTERIES.  (Special Anat.)
323
sively in the substance, of the lower lip,
where it anastomoses with the submental,
the dental, and  the inferior  coronary of
the lip.
  ■>. R. coronarius labii inferior.  (Fig.
4. c.) The facial artery, pursuing a  ser-
pentine course towards the angle of the
mouth, divides about midway between the
lower jaw and the  point just mentioned,
into two branches, one of which preserves
the original direction of the vessel;—the
other,  the  inferior  coronary, advancing
forwards, glides beneath the depressor an-
guli oris, and winds  in a tortuous direction
through the substance of the  lower lip, a
little exterior to the mucous membrane
of the mouth, and sends numerous ramus-
culi to the orbicular and depressor mus-
cles, and to the integuments of  the lip
and chin.  It forms a free anastomosis with
its fellow of the  opposite side, as well as
with the superficial inferior  labial, when
it exists, and with the dental and submen-
tal branches.
  i. R.  coronarius  labii superior. (Fig.
4. g.)  This  branch, which is larger and
more tortuous than the preceding, sepa-
rates from the facial opposite  the angle of
the mouth, glides beneath the zygomatic
and levator muscles, and plunges into the
substance of the upper lip, along the mar-
gin of which it winds its tortuous course,
sending ramifications to the orbicular mus-
cle, the several  elevators, to the mucous
membrane  of the mouth, and finally ter-
minates by anastomosing with the artery
of the opposite  side.  Near  its termina-
tion, it sends one or more small ramusculi
upwards (r. septi nasalis), which ascend
in a perpendicular  direction  towards the
septum of the nose, along which  they ra-
mify, and  terminate near the tip, by a
free anastomosis.   The superior labial,
likewise, sometimes gives off the r. pin-
nalis, to the  ala of the nose;  but  this
branch  more frequently arises from  the
facial.
  Both the coronary arteries  are tortuous,
because of the great mobility of the parts
to which they are distributed.  They  are,
moreover, exceedingly  variable  in their
origin  and distribution.   One or both of
them sometimes come from the transverse
facial, and in such cases, the  proper facial
is smaller than usual. The inferior is not
unfrequently wanting, its place being sup-
plied by the  ramusculi of the submental,
the dental, or the inferior superficial labial.
  *. R. lateralis nasi, s. pinnali (Fig. 4),
are small ramifications given off by the
facial a few  lines higher up, where it is
covered by the levator labii superior's et
alae nasi.  They are distributed extensively
upon the ala and dorsum of the nose,
where they form a kind of plexus by an-
astomosing with  their congeners of the
opposite  side.  Some of them are occa-
sionally denominated r. dorsales nasi. The
facial then ascends between the two at-
tachments of the levator labii superioris
et ate nasi, anastomoses with the ramifi-
cations of the infra-orbital, sends branches
to the lower eye-lid, ascends by the inter-
nal angle of the  eye, and  terminates by
anastomosing  with the  ramifications of
the nasal and supra-orbital branches of
the ophthalmic, and by distributing small
ramusculi to the  lachrymal sac  and the
orbicular muscle of the eye-lids.
  The ramifications of this artery upon
the face  are exceedingly numerous, and
form an intricate plexus throughout nearly
the whole facial  region, as well  by the
frequency of their communications  with
each other, as through their anastomosis
with the transverse facial, the  infra-or-
bital, and inferior dental of the  internal
maxillary,—and the ophthalmic branch of
the internal carotid.
  d. The inferior pharyngeal artery (r.
pharyngeus inferior,  s. ascendens) is the
only branch given off by the carotid inter-
nally, and is the smallest of the branches
which take  their origin  from that vessel.
It is profoundly situated,  and  usually pro-
ceeds from the external carotid near the
origin of the lingual or facial,—sometimes
by a common origin with one of those ves-
sels, and occasionally from the bifurcation
of the common  carotid.   It ascends, co-
vered  at first by the stylo-pharyngeus
muscle, between  the  internal and exter-
nal carotids, by the  side of the pharynx,
and in front of the anterior rectus muscle
of the head.  In its course,  it sends off
numerous ramusculi to the adjacent parts:
  r*. R.  pharyngeii,  generally three  in
number, distributed inwards;—the two in-
ferior, to the corresponding constrictors
of the pharynx, through which they ra-
mify to reach the mucous membrane, and
to the stylo-pharyngeus  muscle; the su-
perior, to the upper  constrictor,  the eu-
stachian  tube, arches of the palate, ton-
sils, and even  the posterior part of the
nares.
  (3. it*, externes,  s. cervicales.  These are
small and irregular.   They are expended
mostly upon the  superior  cervical  gan-
glion of  the  sympathetic, the  pneumc-
gastric, hypoglossal and  spinal accessory
nerves,—the deep-seated muscles of the
neck, and the lymphatic glands.
  y. R. meningeii, consisting of numerous 
324                       ARTERIES.  (Special Anat.)
ramusculi of variable size, which are dis-
tributed to the base of the cranium, the
dura mater, and other adjacent parts. One
of these, larger than the others (r. menin-
geus posterior), accompanies the internal
jugular vein to  the posterior foramen la-
cerum, through which it passes, between
the vein and the pneumo-gastric nerve, to
supply the dura  mater in that part of the
skull.  Sometimes  it traverses the bone
by a separate foramen situated near the
mastoid process. Another ramusculus tra-
verses the base of the cranium by the an-
terior foramen lacerum, or the irregular
opening formed  by the rough extremity
of the petrous  portion of the temporal
bone and the body of the sphenoid, to sup-
ply the dura  mater  in  the  vicinity of the
sella turcica.  There  are,  besides,  some
other small ramifications expended mostly
upon the bones and the dura mater.  One
of these passes through the anterior con-
dyloid  foramen,  to  the parts within the
cranium.
  e. The occipital  artery  (Fig. 2. g, z.)
r. occipitalis) is the first and largest of the
branches given off by the external carotid
posteriorly; but is smaller  than either the
lingual or facial, nearly opposite to which
it takes its origin.   It courses backwards
and upwards, below, and parallel with the
posterior belly of the digastric muscle, in
front  of the internal  jugular vein, the
pneumogastric, spinal  accessory, and hy-
poglossal nerves, the latter of which hooks
around  it to take  its  course towards the
tongue.  It then glides beneath the upper
part of the sterno-cleido-mastoideus mus-
cle, over the surface of the rectus capitis
lateralis,  and in the space between the
transverse process  of the  atlas  and the
mastoid process, where it  is deep-seated.
Here its course is  horizontal for a small
distance, first beneath  the trachelo-masto-
ideus,—afterwards beneath the complexus
and splenius muscles, and  again ascend-
ing, after having arrived near the inner
part of the crucial  ridge of the occipital
bo«e, it perforates the cranial attachment
of the splenius, and ramifies  extensively
upon  the  posterior  part of the head.  It
furnishes the following branches:—
  a. Several small ramifications to the
digastric, stylo-hyoid,  and  sterno-cleido-
mastoid  muscles,—to the parotid,  and
lymphatic glands of the upper part of the
neck.
  0. A small  ramusculus follows the course
of the internal  jugular vein,  and  pene-
trates the  posterior  foramen lacerum, to
be distributed to the dura mater.
   y. From the same vicinity, it detaches
a small posterior auricular branch, which
advances  upwards  and  forwards  to the
lobe of the  ear; and  a  second, denomi-
nated posterior temporal, which ascends
behind the ear, and is distributed to the
concha.
  t. In the vicinity of the mastoid pro-
cess, it sends off a mastoid branch, which
traverses  the foramen  of the same name,
to  reach  the  posterior part of the dura
mater,—small ramusculi to the rectus ca-
pitis  lateralis, trachelo-mastoideus,  com-
plexus, splenius and semispinalis colli.
  f. On a level with the transverse pro-
cess of the  atlas, it detaches a consider-
able descending branch (r. princeps cervi-
cis), almost equal in size to the continuous
portion of the vessel.   It frequently de-
scends for some distance upon the back,
in  the  space between  the  semispinalis
colli, sends ramusculi into all the adjacent
muscles,  and anastomoses  in its course
with the branches of the  ascending, trans-
verse, and profound cervicals, and,  on a
level  with each intervertebral space, with
the branches of the vertebral.
  t}. A small, transverse branch is sent off
near the occiput which, taking its course
across the recti and oblique  muscles of
the head,  unites with its fellow of  the op-
posite side,  and forms an arch, with ite
concavity downwards.   From this, small
ramusculi are detached to the adjacent
muscles.
  The occipital artery, having perforated
the  cranial attachment  of the splenius
muscle, becomes superficial, and  divides
into several tortuous branches, which pur-
sue an arborescent distribution over the
whole of  the  posterior part of the head,
supplying the scalp and  the bone, and
forming an intimate  anastomois,—ante-
riorly, with the posterior  auricular and the
temporal,  and posteriorly, with  the occi-
pital of the opposite side.
  f. The posterior auricular artery (Fig.
2. h.)  (r.  auricularis  posterior, s. stylo-
mastoideus) is much smaller than the oc-
cipital, and arises from the  posterior part
of the external carotid a few lines higher
up, a little above the level of the digastric
and stylo-hyoid muscles.   Sometimes it is
a branch  of the occipital.  Concealed at
its origin  by the parotid gland, in the pos-
terior part of which it  is partially embed-
ded, it advances upwards and a little back-
wards, between  the mastoid process and
the ear, and  terminates  by anastomosing
on the side of the head with the occipital
and temporal  arteries.  It furnishes the
following  ramusculi:
  o. R. to the posterior belly of the di- 
ARTERIES.  (Special Anct.)                      325
gastric muscle, and to the stylo-hyoideus
and parotid gland.
  p.  R. stylo-mastoideus, which  pene-
trates  the  stylo-mastoid foramen  of the
temporal bone, and traverses the aqueduct
of Fallopius.   It  sends one  or more
branches to the membrana tympani, which,
by anastomosing with a small ramusculus
from the internal maxillary,  forms a kind
of circle around that membrane, sending
minute vessels to  it, to the  lining mem-
brane of the external meatus of the ear,
and to the adjacent portion of the mucous
membrane of the cavity of the tympanum.
It likewise  distributes branches  to  the
mastoid cells, to the whole of the lining
of the tympanum, to the  muscles of the
internal ear,  and to the concha, vestibule,
and semicircular canals.   It finally termi-
nates by anastomosing with a small branch
of the meningeal artery, which enters the
petrous portion  of  the  temporal  bone,
through the hiatus Fallopii.
  y. The  artery then  ascends between
the mastoid process and the ear, and di-
vides into anterior and posterior branches.
The first, which are minute, ramify upon
the back part of the concha,  between the
integuments  and the cartilage, and upon
the posterior  auricular muscle.   The pos-
terior branch, somewhat  larger, courses
over the  root of the mastoid process, and
distributes  ramusculi to the occipital, tem-
poral, mastoid, and splenius muscles, and
to the integuments  of the  cranium, anas-
tomosing on the one hand with the poste-
rior branches of the temporal artery, and
on the other with the occipital.
  The  external  carotid   artery having
given off these  ramuli, and  reached the
level  of the  neck of the condyle of the
lower jaw, divides while  yet concealed
by the parotid gland,  into the  temporal
artery, which  may  be regarded  as  the
continuation  of the vessel, and the inter-
nal maxillary, distributed to the deep-seat-
ed parts about the face.
  g. The superficial temporal artery. (Fig.
2. i. Fig. 5. b.)  (R. temporalis superfici-
alis.)  This  branch  is smaller and more
superficial than the internal maxillary.  It
ascends  in the  original direction of the
external  carotid artery, between the ar-
ticulation of  the lower jaw, the external
meatus of the ear, and the parotid gland,
being  covered by the latter, as high  as
the posterior  root of the zygoma.  At this
latter point  it becomes superficial, and
glides  in a tortuous direction beneath the
anterior  auricular muscle, where  it re-
poses  upon the upper branch  of the root
of the  zygomatic process, covered by the
  vol. ii.          29
skin and a slip of the temporal fascia, and
can be conveniently compressed.  It con-
tinues its course upwards upon the sur-
face of the temporal aponeurosis, invested
in a kind of sheath  furnished by that
structure, and a little above the zygoma,
divides into anterior and posterior branches,
which ramify in an arborescent manner
upon the whole of the side of the head.
(Fig. 4. d.)   The branches furnished by
the superficial temporal artery are,—
  a. Small ramusculi to the parotid gland,
and  the  structures which  enter into  the
formation of the articulation of the lower
jaw.  A small branch  traverses the gle-
noid fissure of the temporal bone, to reach
the membrana tympani, where it anasto-
moses with a branch of the posterior au-
ricular, and supplies that  membrane, as
well as the muscle of the malleus.
  |3. R. massetericus superior.  The  su-
perficial  temporal artery generally sends
one  or more small ramifications forwards
to the masseter muscle, and to the integu-
ments of the cheek,  which anastomose
with the branches of the labial.
  y. R. transversalis faciei.  (Fig. 2. k.)
A few lines above the division of the  ex-
ternal carotid  artery  into the internal
maxillary and temporal, the  latter gives
off  the transverse facial branch,  which
emerges from the parotid gland by which
it is at first  concealed, takes its  course
forwards over the  surface of the  upper
part of the masseter muscle, between  the
duct of the parotid gland and the zygoma.
It is accompanied  by  two or three fila-
ments of the facial nerve, and in its course,
distributes ramusculi to the parotid and
socia parotidis,—the masseter, temporal,
zygomatic, and palpebral muscles, and ra-
mifying upon the face, terminates by form-
ing a free anastomosis with the infra-or-
bital, alveolar, facial, and  anterior tempo-
ral  arteries.   It also  anastomoses with
some of the branches of the internal max-
illary.  When  the facial is very small or
imperfect, the superior labial, and the  na-
sal branches of that vessel, are furnished
by the transverse facial.
  f. R. temporalis medius, vel profundus,
likewise takes  its origin from the super-
ficial temporal,  usually a little below the
zygoma,—sometimes above it. Advancing
obliquely upwards and forwards, it  distri-
butes  small  ramusculi to  the masseter
muscle, glides over the surface of the zy-
goma, and perforating  the temporal apo-
neurosis on a level with the upper margin
of that arch, ramifies extensively in the
temporal muscle,  and  anastomoses with
the deep temporal branches of the internal 
326                       ARTERIES.  (Special Anat.)
maxillary:—some of its superficial rami-
fications likewise advance towards the an-
gle of the eye, and anastomose with the
palpebral.
  t.  R. auriculares anteriores inferiores,
et anteriores superiores.  While the tem-
poral artery is ascending in front of the
ear,  it sends several small branches back-
wards to the anterior and inferior part of
the auricle, and to the superior portion of
the same, as well as to the upper auricular
muscle.   They arise from  the  temporal
in a successive series, and  are  denomi-
nated  inferior  and superior anterior auri-
cular branches, in contradistinction to the
posterior.
  Having ascended above the level of the
root of the zygoma, and reached the sur-
face of the temporal muscle, the temporal
artery divides  into an anterior and poste-
rior branch.
  £.  R. temporalis anterior, s. frontalis
(Fig. 4. d.) pursues a tortuous course up-
wards and forwards towards the forehead,
and spreads its arborescent ramifications
over the whole of the anterior lateral part
of the head. They supply the integuments
of the cranium, the temporal muscle, the
orbicularis palpebrarum, and the corruga-
tor supercilii.  They anastomose near the
external angle of the eye, with the facial;
—in the  supercdiary  region,  with the
frontal and supra-orbital  branches  of the
ophthalmic; and near  the glabella, with
the  branches  of the opposite side.
   *j. R. temporalis posterior, vel occipi-
talis.   This branch, which  may be  re-
garded  as  the  termination of the  su-
perficial  temporal,  mounts  upwards and
backwards upon the lateral and posterior
part of the head.  It divides into numer-
ous ramifications, which present an arbo-
rescent arrangement.  They supply the
 integuments of the cranium, and anasto-
 mose, anteriorly, with the anterior tempo-
 ral ; on the vertex, with  the branches  of
 the opposite  side; and posteriorly, with
 the occipital and posterior auricular.
   The temporal   and  occipital  arteries,
 spread out as they are upon  the whole su-
 perficies of the head, not only supply the
 whole of the soft parts which occupy this
 region, and form an intimate anastomosis
 by all their branches, but likewise distri-
 bute an infinity of minute ramusculi into
 the diploe of the bones, by which an inti-
 mate  and important association is formed
 between them and the vessels within the
 cranium.
   h. The internal maxillary artery (Fig.
 5. a.)  (r. maxillaris internus) is larger
 than the temporal.  From the multiplicity
of its branches and their complicated dis-
tribution, it is difficult to render them in-
telligible by  mere  description.  It sepa-
rates from the temporal in the substance
of the parotid gland, and on a level with
the neck of the condyle of the lower jaw.
In its course  forwards to the deep-seated
parts of the  face which it supplies, it is
                 Fig. 5.
o. Internal Maxillary, b, Superficial Temporal. /, Facial.
exceedingly tortuous, and changes its di-
rection several times. Tracing it from its
origin from the external carotid, or rather
from the point at which it separates from
the temporal, it may be divided into three
portions, founded upon the direction pur-
sued by it.
  1. It advances downwards and inwards to
sweep round the inner surface of the neck
of the condyle of the lower  jaw, and be-
tween it and the internal lateral ligament;
—then inwards between the two pterygoid
muscles, and the  inferior dental and the
lingual nerves, and here changing its direc-
tion again, it advances  forwards towards
the tuber of the superior maxillary bone,
where it terminates in the second, or ver-
tical portion.  The course of this first part
of the artery is nearly horizontal.
  2. Having reached the pterygoid pro-
cess, the internal maxillary artery ascends
in nearly a perpendicular direction,  be-
tween the attachments  of the  external
pterygoid muscle,  and glides between the
surface  of the zygomatic fossa and the at-
tachment of the temporal muscle, untd it
arrives near the bottom of the orbit, where
it again changes its direction.
  3. Near the level of the bottom of the
orbit, the artery assumes, a  second time,
a horizontal  course,  and advancing  for-
wards and inwards, plunges into the sphe-
no-maxillary fossa,  and  terminates by di-
viding into several branches,  one of which
runs forwards along the infra-orbital ca-
nal, to be distributed upon the face.  The 
ARTERIES. (Special Anat.)
327
branches given off by the internal maxil-
lary artery may be divided into three se-
ries, according as they proceed from these
three portions of the vessel.
  Branches given off between the origin
of the artery and the pterygoid process:
  a. R. auricularis profundus is a small
irregular ramusculus, which proceeds to
the external meatus of the ear, and is dis-
tributed to it and the neighbouring parts.
  p. R. tympanicus.  This is also a small
branch, which, coming off near  the  arti-
culation  of the lower jaw, sends minute
ramusculi to that joint, and penetrates the
glenoid fissure of the temporal  bone, to
supply the laxator tympani muscle, and
the adjacent portion of the mucous mem-
brane lining the internal ear.
  y. R.  meningeus  parvus s. pterygoi-
deus externus is generally a small branch
originating in the vicinity of the preced-
ing,—sometimes  from  the great menin-
geal, or one of the pterygoideal branches.
It advances upwards towards the base of
the skull, and distributes small branches
to the inferior maxillary nerve, the exter-
nal  pterygoid muscle, and  to the circum-
flexus and  levator palati muscles.   Then
entering the cranium through the foramen
ovali, it supplies the dura mater in  the vi-
cinity of the sella turcica.
  £. R. meningeus medius s. magnus, s.
spinosus.   This is a branch of consider-
able size.  It arises from the upper part
of  the  internal  maxillary artery,  and
mounting directly upwards  on the outer
side of the internal lateral  ligament of the
lower jaw,  and  between  the two ptery-
goid muscles, towards the foramen spinale
of the sphenoid bone, it enters the crani-
um by that opening, and is distributed ex-
tensively to the dura mater.  In its course,
before it  enters  the cranium,  it  sends
small branches to the pterygoid and tem-
poral muscles; the superior constrictor of
the pharynx; the  eustachian tube, and the
circumflex and levator muscles of the pa-
late.  A few  also traverse the sphenoid
bone, or pass through the anterior foramen
lacerum to the dura mater at the base of
the cranium.  The artery then  glides
through the foramen spinale of the sphe-
noid bone,  and becomes lodged in  a  deep
furrow,—sometimes  a  perfect canal, on
the inner side of the anterior inferior an-
gle of the parietal bone.  Within the cra-
nium, it distributes small ramusculi to the
fifth pair of nerves and the adjacent por-
tion of the  dura  mater: a small  branch
which enters the orbit through the greater
wing  of the  sphenoid,  through the malar
bone,  and sometimes through the spheno-
maxillary fissure,  to be expended upon
the lachrymal gland: a branch also pene-
trates  the  hiatus Fallopii, and traverses
the aqueduct of the same name,—sending
in its course ramusculi to the facial nerve,
to the  lining membrane of the tympanal
cavity, the internal muscle of the malleus
and  the  membrana tympani;—it  finally
terminates by anastomosing with the sty-
lo-mastoid branch.   The terminal portion
of the  middle meningeal  artery consists
of an  anterior and  a posterior  ramulus,
which  branch out  upon  the  internal
surface of the parietal bone, and  in the
substance of the  outer  surface  of the
dura mater, and make  a  beautiful arbo-
rescent impress upon the former,  repre-
sented  by a number of superficial grooves,
in which the  ramifications are  lodged.
The anterior  branch, directed  upwards
and  forwards, follows the course  of the
coronal suture, and  anastomoses in  the vi-
cinity of the  longitudinal  sinus with the
branches of the opposite side, and, further
forwards, with the ophthalmic.  The pos-
terior,  in a similar manner, advances up-
wards  and backwards, and  after ramify-
ing  extensively,  anastomoses  with the
branches of the opposite  side,  and with
the posterior meningeal arteries furnished
by the  spinal and the occipital.  Numer-
ous ramusculi also  penetrate the bone to
supply the diploe,  and others  penetrate
the sutures to anastomose with the vessels
of the  scalp.
  c. R. maxillaris inferior,  s. dentalis, s.
alveolaris inferior.  The inferior  dental
artery  generally takes its origin  from the
lower  part of the  internal maxillary, op-
posite  the point at which the middle me-
ningeal is given off. It advances forwards,
along the inner side of the neck  of the
lower jaw, and between the internal sur-
face of that bone and the internal ptery-
goid muscle, and enters the posterior den-
tal foramen.  Traversing  the bony canal
which  occupies the  alveolar portion of the
jaw, it detaches from its upper surface
small ramusculi which penetrate the fang
of each tooth, to supply its pulp.  Having
arrived near the chin, it divides into two
branches, one of which, after running a
small distance, escapes through the men-
tal  foramen,  and  is distributed to the in-
teguments and muscles about the chin,
anastomosing above with the inferior la-
bial, below with the  submental, and on
the median line with the branches  of the
opposite side. The other branch continues
to traverse the alveolar  process  to the
symphysis of the chin,  and supplies the
fangs of  the  incisor teeth. 
328                       ARTERIES. (Special Anat.)
  Previously to  entering  the maxillary
canal,  the  inferior dental artery detaches
small ramusculi to the internal pterygoid,
temporal, and buccinator muscles; to the
dental and lingual  nerves,  and the  adja-
cent glands.  Where it is about to enter
the bone, it gives off a small ramification
which glides along the inner surface of
the lower jaw, following accurately the
course of the mylo-hyoid nerve, and sup-
plying the mylo-hyoid muscle, the mucous
membrane  of the floor of the mouth, and
other structures in the vicinity.
  Branches furnished by the vertical or
ascending portion of the internal maxil-
lary artery :
  f. R.  temporalis profundus posterior.
  This small branch arises  near the last
and  is concealed at first by the temporal
and pterygoid muscles. It ascends covered
by the latter  muscle, and between it and
the surface of the cranium, into the  tem-
poral fossa, where it terminates by distri-
buting numerous ramifications to the  tem-
poral muscle  and periosteum, and  anasto-
mosing anteriorly with the anterior deep
temporal, and posteriorly with the branches
of the  middle and  superficial temporals.
Near its origin, it gives small branches to
the pterygoid and buccinator muscles.
  y. R. pterygoideus is a small muscular
branch, which comes off near the preced-
ing, and is sometimes a branch of it. Very
generally  there  are  several of  these
branches, which are exceedingly variable
in size and number. They are distributed
to the internal and external pterygoid, and
the buccinator  muscles.  Some of them
ascend in the temporal  fossa, and follow
the course  of the posterior deep temporal
artery.
  i.  R. massetericus, like the preceding,
is very small and irregular.   It likewise
arises  from the internal maxillary, where
it courses upwards between the pterygoid
muscles.  It  advances outwards, through
the  semilunar  notch  of the  lower  jaw,
sending ramifications  in its course to the
temporal  and  pterygoid  muscles,   and
plunges  into the  masseter muscle,  in
which  it ramifies  very  extensively.  It
often arises from the posterior deep  tem-
poral, or from the middle meningeal.
  x.  R. buccalis  is  a small  irregular
branch, frequently arising from  the  deep
temporal, the meningeal, or the inferior
dental.   It proceeds from the lower part
of the internal  maxillary, and advancing
forwards and downwards, sends numerous
ramusculi into the buccinator muscle, the
zygomaticus  minor and major, the mucous
membrane  of the mouth, and to the other
adjacent structures  of the  face,—espe-
cially to those situated near the  angle  of
the mouth.   It  anastomoses  freely  with
the transverse facial, the infra-orbital, and
the facial arteries.
  X. R. temporalis  profundus  anterior.
This  branch arises  higher up  than the
preceding.   It advances directly upwards
in the anterior part of the zygomatic fossa,
between the temporal muscle and the sur-
face of the  cranium.  It sends numerous
ramusculi into that muscle, which anasto-
mose  with  the  posterior  deep, and the
middle temporal artery.  It also gives off
a small branch which traverses a foramen
of the malar bone, to reach the lachrymal
gland, and others of the same  character
to the fatty substance within the orbit.
  p..  R. dentalis s. alveolaris  superior.
This is a considerable branch, which some-
times arises from the anterior temporal, or
the infra-orbital.  It takes  its origin near
the tuber of the  superior maxillary bone,
around  the   outer  surface of  which it
twines  in a  tortuous  direction.  It first
sends numerous  small  branches through
the posterior foramina of the bone, to sup-
ply the large molars, and others which
are expended upon the. mucous membrane
which lines the antrum;—then advancing
forwards, along the surface of the alveo-
lar  process, and  in the substance of the
gums,  as far as the canine  tooth, it there
sends small branches to the lesser molars,
and terminates in several small branches
which are distributed to   the buccinator
muscle, the fat of the cheek, and  the gums
and periosteum.  One of these  branches
anastomoses with the infra-orbital.
  Branches terminating the internal max-
illary artery:
  v.  R.  infra-orbitalis takes  its origin
near the bottom  of the orbit, and immedi-
ately  assumes a  horizontal direction for-
wards, to engage itself in the infra-orbital
canal,  the  whole  length of which  it
traverses,  and  finally escapes upon the
face through  the infra-orbital  foramen,
and beneath  the levator labii superioris.
Previously to entering the  canal, it sends
small branches   to the fat  and perios-
teum  of the  bottom  of the orbit, and to
the inferior rectus muscle.   It also distri-
butes branches to the inferior oblique  mus-
cle, the orbicularis  palpebrarum, and to
the lachrymal sac.  While lodged in the
canal, it sends small branches downwards
into  the antrum, to supply  its mucous
membrane;  and  near  its  orifice, one  or
more  branches  are  sent  to  the canine
and  incisor  teeth.  Those which reach
the face are  distributed to  the upper lip, 
ARTERIES. (Special Anat.)
329
where they form a complex anastomosis
with the superior dental, transverse facial,
superior labial,  and the nasal branches of
the facial.
  f*.  R. vidianus  is  a small  reflected
branch, which proceeds backwards through
the vidian foramen, in company with the
nerve of the same name, and is distributed
to the upper part of the pharynx,  the
sphenoidal sinus, and the eustachian tube.
It is  frequently a  branch of the superior
palatine.
  o. R. palalinus superior, s. descendens.
This branch comes off in the sphenomax-
illary fossa near the bottom of the orbit,
whence it descends in a perpendicular di-
rection in the pterygo-maxillary fissure
to engage  itself in the posterior palatine
foramen.  Having  traversed this opening,
it sends small branches to the soft palate,
and takes its course  forwards  along  the
lower surface of the bony vault of the pal-
ate and between it and the mucous mem-
brane of the mouth, to which,  as well as
the gums, it sends  small ramusculi.   One
of its terminal branches finally penetrates
the anterior palatine  foramen, through
which it ascends  into the nose, where it
anastomoses with the nasal branches fur-
nished by the facial.
  *.  R. pharyngeus superior, s. descend-
ens is frequently a branch of the preced-
ing, or of the spheno-palatine.  It mount's
upwards and forwards, and becomes en-
gaged in the  pterygo-palatine foramen,
which it traverses, and is  afterwards ex-
pended upon the upper part of the  pha-
rynx, the  eustachian  tube, and the body
of the sphenoid bone.
  f. R. spheno-palatinus, s. nasalis pos-
terior.  This is the last branch of the in-
ternal maxillary artery, and may be re-
regarded  as its proper termination.  It
ascends through the pterygo-palatine fora-
men to the posterior nares, and either be-
fore it has traversed  that opening,  or af-
terwards, divides into external and inter-
nal branches.  The first enters the  nose
near  the posterior part  of the  upper me-
atus, where  it  is covered by the mucous
membrane.   It sends ramusculi to the su-
perior and  inferior turbinated  bones,  to
the mucous membrane lining the nose, to
the posterior ethmoidal cells, to the sphe-
noidal sinus, and likewise to the antrum.
One  or more  of  these branches anasto-
mose with the  anterior palatine after it
has traversed the foramen incisivum.  The
internal branch goes to  the septum of the
nose, and ramifies extensively  upon the
mucous membrane. It distributes, besides,
several small ramusculi to the upper part
                28*
of the pharynx, and some to the ethmoidal
cells.
  Varieties of the external carotid artery
and ils branches.  Several varieties in
the origin of the carotid arteries have
been  already  mentioned.   Those  which
remain to be noticed, have reference par-
ticularly to the point at which it divides
in the neck.  Generally, the common ca-
rotid divides into external  and internal on
a level with the upper margin of the thy-
roid cartilage.   Burns,  however, has de-
scribed a case, iu which the division took
place much lower—on  a  level with the
sixth cervical vertebra. The trunks, which
were  of nearly equal size, mounted up
the  side of the larynx  parallel  to each
other, and were  enveloped in the same
sheath with the internal jugular vein and
the  pneumogastric nerve.   (Observat. on
the  diseases of the heart, p. 285.)   An in-
stance has likewise been reported by Mor-
gagni (De sed. et caus. morb.  Lib. III. ep.
xxix. 20.), in which the left common ca-
rotid divided six  inches above its origin.
Sometimes the common carotid gives off
branches laterally as it advances upwards,
and does  not  divide until it reaches the
styloid process, where it terminates in two
branches,  one of which is  the internal ca-
rotid,—the other the common origin of
the  temporal   and  internal  maxillary.
(Burns. Loc. Cit.)  In  another  case de-
scribed  by Burns,  the external carotid
was a short thick stump, resembling the
axis arterise  cceliacs, from  the top of
which the several branches took their ori-
gin.  This interesting preparation is now
before us, and belongs at present to the
collection of the University of Maryland.
A similar example has been  figured by
Munz. (Handbuch der Anatomie, mit Ab-
bildungen. T. vi. fig. 4.)
  The superior thyroid artery is subject
to several varieties in its origin and dis-
tribution.   Sometimes it  arises from the
common carotid below the point at which
that vessel divides. (Burns.)  It  is, in a
few instances, wanting on one side, or re-
markably small;  the defect in such cases
being compensated by the greater devel-
opment of the  inferior thyroid.  Occasion-
ally it arises from the external carotid, by
a common trunk with the  lingual.  Some-
times there is a  second superior thyroid,
which arises  from the  external carotid
above the first;  and  in such cases, the
upper one occasionally  furnishes the la-
ryngeal branch and the  lingual artery.
(Tiedemann. Tab. VII.  fig. 1.)  The la-
ryngeal branch  is not  unfrequently a
branch of the external carotid; and some- 
330
ARTERIES.  (Special Anat.)
times it  arises from the lingual. (Munz.
Tab. VIII.)
  The lingual artery, besides arising in
some cases  in common with the superior
thyroid, may come off by a common trunk
with the facial. (Burns.)   This latter ar-
tery sometimes furnishes the  sublingual
branch, and in a  case in which there was
a second superior thyroid, Tiedemann ob-
served the  dorsal is  lingua? arising from
the lower one, while the  other vessels of
the  tongue  proceeded  from  that  which
came off above.
  The facial, or external maxillary ar-
tery, arises,  in some instances, in common
with the lingual.   Sometimes it furnishes
the a. ranina. (Meckel.)  Occasionally it
is preternaturally small, and does not ex-
tend beyond the corner of the  mouth; and
in two or three cases observed by Burns,
it was not  larger than  a sewing-thread
where it passed over the lower jaw.  Un-
der  such circumstances, the  transverse
facial artery supplies the lips and nose.
In another instance observed by the same
author, the  facial artery took its  origin
from the temporal, near the angle  of the
jaw; and there  was, besides, given off
from  the portion of the external carotid
which usually furnishes the facial artery,
a branch which  supplied the submental,
and  then ascended behind the ascending
plate of the  lower jaw,  supplying the
place  of the internal  maxillary artery.
(Op. Cit. p. 289.)
  The pharyngeal artery sometimes arises
in common  with the facial  (Sabatier,
&.c.); sometimes  from the occipital.  (Hal-
ler, Green.)  It has been seen arising,
in several instances,  from the bifurcation
of the carotid, as the sacra  media  does
from the bifurcation of the aorta.  (Green.
 Varieties of the arterial system, p. 9. Dub-
lin, 1830.)  In some instances it  comes
from  the   superior  thyroid.  (Mayer.)
Sometimes  there are two pharyngeal ar-
teries,—one from the external, and one
from the internal carotid. (Haller, Soem-
mering.) The same authors report, that
they have seen three.  In such cases, one
branch usually proceeds from the  facial.
(Tiedemann.)
   The occipital artery was observed once
by Haller,  and twice  by Tiedemann,
arising from the  internal carotid.  A case
was reported to Green, in which it arose
from the vertebral.
   The posterior auricular artery  some-
 times comes off higher up  than  usual,
 near the division of the external carotid
 into the temporal and internal maxdlary.
(Barclay.)   In  some  instances, it is  a
branch of the occipital. (Haller.)
  The stylo-masloid, which is generally
a branch  of the  posterior auricular, not
unfrequently arises  from  the occipital;
and in one instance, Haller saw it coming
off from the external carotid.
  The varieties of the temporal and in-
ternal maxillary arteries are too unimpor-
tant to deserve  much attention.  When
the facial is small, the transverse artery
of the  face  is generally large,  and sup-
plies the  superior labial branch, as well
as those which are proper to the nose.  In
one case,  Sabatier saw the middle me-
ningeal  artery   entering  the   cranium
through the squamous  suture.  In some
instances, this artery furnishes the lachry-
mal, which is usually a branch of the oph-
thalmic.   In such examples, it enters the
orbit through the  greater wing of the
sphenoid.  (Soemmering.)
  F. The internal carotid artery.  (Fig.
2. I.)   (R. carotis internus, s.  cerebralis.)
The point at which this vessel separates
from the external carotid artery on a level
with the cartilages of the larynx, has been
already described.  It  is generally some-
what smaller than that vessel,  and at its
origin  forms a  slight curve outwards,
which  renders it more superficial there
than at any other point.  It then ascends
in front of  the cervical vertebra, and be-
hind the digastric and styloid muscles and
parotid gland, to the base of the cranium,
where it  enters the carotid canal of the
petrous portion   of  the  temporal  bone,
which it traverses to reach the  cavity of
the cranium.  It is finally distributed to
the anterior part of the brain, and the eye.
  In studying the  relations and distribu-
tion of the internal carotid artery, it should
be divided into three portions:
  The first or cervical portion, comprises
the part between the origin of the  artery
and its entrance into the carotid canal. It
is slightly  flexuous, and  becomes more
and  more profound as it  ascends.  It re-
poses posteriorly upon  the rectus capitis
muscle, the pneumogastric and sympa-
thetic  nerves, and the superior cervical
ganglion:  anteriorly,  it  is accompanied
by the external carotid artery and the ju-
gular vein;—and it is,  besides, crossed in
front by the digastric and styloid muscles,
and the  lingual and  glosso-pharyngeal
nerves.  Finally, at its upper part, it is
profoundly situated, and is covered  by the
parotid gland.  The internal jugular vein,
which is in  front of the internal carotid, is
also inclined slightly towards  its external 
ARTERIES.  (Special Anat.)
331
Bide; while along its  internal surface, it
is in contact below with the pharynx,
and above, is but slightly removed from
the  tonsils, with  which  it is connected
by  loose cellular tissue.   In  this course,
the  artery does  not usually  furnish any
branches;  but occasionally it supplies one
or more of those which are generally sent
off by the external carotid, and, more fre-
quently, a small branch to the palate and
fauces.
   The second part of the artery is lodged
in  the  petrous  portion  of the temporal
bone.  It  enters the  carotid  canal in a
perpendicular direction, but immediately
inclines  obliquely forwards, almost in a
horizontal  direction, but  still  advancing
slightly upwards and inwards, along the
outer side of the tympanum and labyrinth,
and parallel with  the eustachian  tube.
Finally, it  escapes from the carotid canal,
where it takes  a direction upwards, for-
wards,  and  inwards, reaches the side
of  the sella turcica, and perforates the
deep layer of the dura mater which forms
the cavernous sinus.  The portion of the
artery which is lodged in  the  carotid  ca-
nal,  is  accompanied by several  small
ascending  filaments of the sympathetic
nerve, which form a plexus upon its sur-
face. It sends a small branch to tl\e tym-
panum, which is distributed to its lining
membrane and the promontory, and anas-
tomoses with the ramifications of the sty-
lo-mastoid  branch and the middle menin-
geal ; and  a second which traverses  the
vidian foramen.
   Finally,  the third,  or  cerebral portion
of  the  internal  carotid artery,   runs  in
nearly a horizontal direction  forwards,
along the side of the body of the sphenoid
bone, embedded in  the  cavernous sinus,
but  separated from its proper cavity by
the  lining  membrane which  is  reflected
upon the course of the  vessel.   In this
part of its  distribution, it is accompanied
by the external motor nerve,  and has the
cavernous ganglion reposing upon its sur-
face. Having reached the anterior clinoid
process,  it assumes a vertical direction
and perforates the dura mater:  then  in-
clining slightly backwards, posteriorly and
externally  to the optic nerve, and carry-
ing with it a reflection of the arachnoid
membrane, it reaches the inner extremity
of the fissure of Sylvius, and divides into
the ophthalmic  (Fig. 6. a.) and cerebral
arteries.
  Whilst engaged in the cavernous sinus,
it distributes small  ramuli to the lining
membrane  of the  sphenoidal sinus, the
dura mater,  pituitary  gland,  and to the
third, fourth, fifth, and sixth pairs of nerves.
The numerous and  sudden flexures pre-
sented by this vessel, during,its transit
through the bone, are particularly worthy
of observation, as  they show  a  provision
of nature well calculated to prevent a too
sudden ingress of  blood upon the delicate
compages of the brain.
                 Fig- 6.
 «, Ophthalmic b, Lachrymal, t. Posterior Ethmoidal.  /. In-
ferior Palpebral, g, Anterior Ethmoidal. A, Nasal,  t, Frontal.
ft. Superior Palpebral.  I, Carotid, m, Optic Nerve.
   a.  Ophthalmic  artery.  (Figs. 6,7. a.)
(R. ophthalmicus.)  The ophthalmic  ar-
tery is a branch of considerable  magni-
tude.  It comes  off from the  curvature
formed by the internal  carotid,  at the
point at which it assumes a perpendicular
direction, by the side of the anterior cli-
noid process, and enters the orbit through
the foramen opticum, placed at first along
the outer inferior part  of the optic nerve,
and  between  the external motor  nerve
and  the  corresponding rectus  muscle of
the eye.   It then ascends slightly, crosses
the upper surface  of the nerve obliquely,
and  running  between it and  the  upper
rectus muscle, inclines towards the inner
part of the orbit and finally advances for-
wards, along the inner side of the nerve, to
the internal canthus of the eye, where it
terminates by dividing into other branches.
   a. R. lachrymalis. (Fig. 6. b.) This is
the largest of the branches furnished by
the ophthalmic, from  the outer part of
which it takes its origin,—generally after
that vessel has entered the orbit, but some- 
332
ARTERIES.  (Special Anat.)
times before.  In the latter case, it passes
through the foramen lacerum, or through
a separate aperture either in the  greater
wing of the sphenoid, or the malar bone.
It advances along  the  superior external
part of the orbit, above the upper edge of
the external rectus muscle, and beneath
the superior rectus and levator palpebra-
rum, towards the lachrymal gland. Hav-
ing  reached that  body, it glides along
either its upper or lower surface, sends
numerous small ramifications into its sub-
stance,  and  divides  into  two branches.
The first, which is inferior, is distributed
to the orbicularis  palpebrarum, where  it
anastomoses along  the margin of the in-
ferior tarsus, to form an arch, with the in-
ferior palpebral and the superficial tempo-
ral.   The second  advances upwards, and
forms a similar anastomosis in the muscles
and  skin of the upper  lid.  Both these
branches ramify extensively in the upper
and  lower eye-lids and  the adjacent por-
tion of the  conjunctiva.
   The lachrymal artery, in the course of
its distribution, sends small branches  to
the dura mater, the cavernous sinus,—to
the external and superior rectus muscles
of the eye, the levator  palpebrarum, the
periosteum, and to the fibrous expansion
of the eye-ball.  It also gives  off small
branches near the anterior part of the or-
bit which traverse the malar bone,  and
anastomose  with the profound temporal.
In some subjects, it furnishes one or more
ciliary branches.
   p. R. centralis retina. (Fig. 7. b.) The
central artery of the retina generally arises
from the ophthalmic, some distance behind
the eye-ball,—sometimes from one of the
ciliary arteries, or even  the  inferior mus-
cular.   It penetrates the outer part of the
optic nerve obliquely, and  traverses the
centre of its axis to the bottom of the eye,
which it enters by one or more branches.
Having thus reached the point at which
the  expansion  of the retina commences,
it distributes a number of extremely deli-
cate  ramifications  upon that structure,
which form a fine vascular net-work upon
the  whole  extent  of its  inner surface.
Some of these ramifications reach the  cor-
pus ciliare, between which and the vitre-
ous humour they form a vascular circle,
and send minute ramusculi to the  crystal-
line lens.  A very delicate branch of the
central  artery advances directly through
the centre  of the  vitreous humour,  and
distributes its minute ramusculi upon the
posterior surface of the  crystalline.
   y. R. supra-orbitalis,  s. muscularis su-
perior  (Fig. 7.  c.)  arises from  the oph-
thalmic while  it  is crossing the  upper
surface of the optic  nerve.   Sometimes
it arises from the  lachrymal, or one of
the  ciliary  branches.   It advances up-
wards beneath  the vault of  the orbit
and  between  it  and the  levator  palpe-
brarum and the superior rectus muscle;
to which  it furnishes branches.  Having
reached the upper margin  of  the orbit
it glides  through  the  superciliary  notch,
and  divides into  an   internal  and  ex-
ternal branch.  The  first ascends  upon
the forehead, supplying the corrugator su-
percilii, the orbicularis palpebrarum, and
occipito-frontalis, and forms a free anasto-
mosis with the frontal and superficial tem-
poral arteries: the. second also ascends to
supply  the  structures  situated  over the
external part of the eye, and anastomose
with the terminal ramifications  of the la-
chrymal.
 a, Ophthalmic 6, Centralis Retinae, e, Supra-orbital,  d, Cili
ares Breves, e. Posterior Ethmoidal, g, Anterior Ethmoidal.  I,
Carotid, m, Optic Nerve.
  8. R. ciliares breves. (Fig. 7. d.)  The
short ciliary  arteries  are  exceedingly
small, and vary both as regards number
and  origin.  They generally  take  their
origin from the ophthalmic in the vicinity
of the  optic nerve, but frequently a part
of them arise from some  of its branches.
They plunge immediately into the bed of
adipose substance  which  surrounds the
optic nerve,  and penetrate  the sclerotic
coat of the eye, near its junction with the
optic nerve, in form of minute ramusculi,
varying in number, from  twenty to forty.
They advance upon the outer surface of 
ARTERIES.  (Special Anat.)
333
the choroid, where,  by dividing at very
acute angles, and forming frequent anas-
tomoses with each other, they develope a
beautiful vascular plexus,  occupying the
whole extent of that membrane, and con-
stituting an important part of it.  They
are finally distributed to  the ciliary bodies
and processes, and to the greater circum-
ference of the iris,  in all of which they
form  a  series of delicate vascular arches
by their numerous anastomoses.  A  few
of them, of small size, do not reach the
choroid, but are expended upon the fat at
the bottom of the eye,  the tunics of the
optic nerve, and the  sclerotica.
   <-. R. ciliares longiores are usually two
in number, one internal, the other exter-
ternal,  which proceed directly forwards
along the corresponding surfaces of the
eye-ball, and perforate the sclerotic coat
in advance of the preceding.  They then
advance in direct lines, along  the outer
surface  of the choroid, furnishing it with
but few branches, and perforate the ciliary
ligament, after which,  each one  divides
into two branches. They anastomose with
several  small branches denominated ante-
rior ciliary, which perforate the sclerotic
immediately behind  its junction with the
cornea, and then reunite with each other,
to form a vascular circle  in the  greater
circumference of the iris.  From the con-
vexity of this arch,  a number  of vessels
proceed to form a similar  one  of smaller
size, and it in its turn sends off an infinity
of delicate branches, which advance  in a
serpentine direction towards the  margin
of the pupil, where, by  inosculating with
each other, they constitute a vascular zone
or circle, surrounding  the entire  contour
of that  aperture.
  f.  R. ciliares antici.  The  preceding
branch, and  sometimes the inferior mus-
cular,  send  off several  small  ramusculi,
denominated   anterior   ciliary  arteries,
which perforate the sclerotica  in the vi-
cinity of its attachment  with the  cornea,
and  anastomose  with  the  long cUiary
branches, to form the vascular zone of the
iris.   Some of their ramifications are like-
wise distributed to the choroid and corpus
ciliare.
  tj. R. muscularis  inferior.   This mus-
cular branch  generally  arises  from the
ophthalmic in the vicinity of  the  optic
nerve, and not far from the origin of the
lachrymal .and ciliary branches.  It  pro-
ceeds forwards and inwards, between the
nerve and the inferior rectus muscle,  and
distributes branches to both these parts, to
the external  rectus, the inferior oblique,
the fat  and periosteum  of the orbit,  and
finally to the lachrymal  sac  and lower
eye-lid, where it anastomoses with the in-
fra-orbital branch.
  "}. R. athmoidalis posterior (Figs. 6,7.
e.) does not exist constantly, and  in some
instances  it arises from the lachrymal or
supra-orbital branches, instead of the oph-
thalmic.   It takes its course towards the
inner part of the orbit, between the inter-
nal rectus and  superior oblique  muscles
of the eye, and becomes engaged in the
posterior ethmoid foramen, which it tra-
verses.  It distributes small  branches to
the lining membrane of the posterior eth-
moid cells, and then enters the  cranium,
where it  sends small ramusculi to the
dura mater in  the  vicinity of the cribri-
form plate  of the ethmoid bone, and fur-
nishes others, which pass with the fila-
ments of the olfactory nerve into the nose.
Several of its  ramifications  anastomose
with the anterior ethmoid branch.
  i.  R. athmoidalis anterior.  (Figs. 6, 7.
g.)  This branch arises  farther forwards
than the preceding, advances directly in-
wards, above the superior oblique muscle,
and enters the nose through the anterior
ethmoid  foramen,  in company  with the
nasal nerve.  It distributes  branches to
the frontal sinuses, and to the membrane
which lines the anterior ethmoid cells. It
then  enters the cranium like the preced-
ing, supplies the adjacent portion of the
dura  mater, and terminates by numerous
small ramusculi, which  pass  downwards
through the cribriform plate of the eth-
moid bone, to be expended upon the lining
membrane of the nose.
   x.  R. palpebralis inferior  (Fig. 6. f.)
usually arises from the ophthalmic a little
beyond the trochlea of the oblique muscle,
but is sometimes given  off by the nasal;
and occasionally it and the inferior  palpe-
bral branch arise by a common trunk.  It
sends  small ramusculi to the lachrymal
sac, the carnucula lachrymalis,  and the
adjacent portion of the conjunctiva.  Then
descending behind the palpebral ligament,
it divides into two branches, one of which
is distributed to the lower half of the or-
bicularis palpebrarum, while the other ad-
vances along the inferior tarsal cartilage,
and supplies it, as well as the meibomian
glands, conjunctiva, and skin, with small
vessels.   It anastomoses with the  infra-
orbital branch, and  with the ramifications
of the transverse facial.
  x. R. palpebralis superior.  (Fig. 6. k.)
This small branch arises near the preced-
ing.  It  sends small  branches to the la-
chrymal sac and caruncle, and  the con-
junctiva;  then perforates the orbicularis 
334                       ARTERIES. (Special Anat.)
palpebrarum  of the upper eye-lid, and
passes outwards along the margin of the
superior tarsal cartilage, sending branches
to it and the adjacent structures,  and ter-
minating  by  anastomosing  with the  la-
chrymal branch.
   Having furnished all  these branches,
the  ophthalmic artery terminates by  di-
viding into two branches,—the frontal
and  the  nasal.
   p.. R. nasalis. (Fig. 6. h.) The nasal ar-
tery is exceedingly variable in size, being
sometimes large, but frequently very small.
It escapes from the orbit above the palpe-
bral ligament whence it descends upon the
nose, supplying the lachrymal sac, the or-
bicularis  palpebrarum, and the adjacent
structures of the nose,—and terminates
by forming a delicate vascular plexus upon
the  latter, by its free anastomosis with
the  facial.  Some  of  its ramusculi pass
through  the  bones and cartdages  of the
nose, to supply the Schneiderian mem-
brane.
   v. R. frontalis (Fig. 6. i.) is generally
somewhat smaller than the preceding.   It
escapes from the upper internal part of
the  orbit, between the orbicularis palpe-
brarum and the bone.  It immediately di-
vides into three or more branches, which
ramify extensively upon the forehead, and
after having  supplied the orbicularis pal-
pebrarum, corrugator supercilii, and fron-
tal muscles, and the adjacent integuments,
anastomoses with the frontal of the oppo-
site  side, and the anterior branches of the
superficial temporal.
   The internal carotid artery having given
off the ophthalmic, proceeds upwards and
backwards, and sends off several branches,
which are expended  upon  the  anterior
part of the brain,—the posterior arteries
of the organ being supplied by the verte-
bral. It sends some unimportant branches
to the posterior part of the optic  nerve,
the  adjacent portions  of the membranes
of the brain, and the infundibulum. Then
ascending, it divides into a series of ante-
rior and posterior branches,—the first of
which is,
   b.  The communicating artery of Wil-
lis.   (R.  communicans Willisii,  s. poste-
rior.)  (Fig. 9. a.)  This branch  varies
much in size, but is seldom absent.  It ad-
vances upwards and slightly inwards, be-
tween the middle lobe of the brain and the
tuber cinereum, and by the side  of the
mamillary eminences, where it meets and
unites with the posterior cerebral branch
of the basilar, thus forming the posterior
part of the circle  of Willis.  It distri-
butes small branches  to the floor  of the
lateral ventricles, the commissure of the
optic  nerves, the optic conches, tuber ci-
nereum,  mamillary bodies,  cruras of the
brain, and the plexus choroides.
  c. Artery of the choroid plexus.   (R
choroideus.)  This is usually a very small
branch, and not unfrequently it arises from
the communicans of Willis.  It proceeds
outwards and backwards, over the surface
of the peduncle of the cerebrum, and after
giving small branches to the pia mater,
plunges into the lateral ventricle, and dis-
tributes  its ramifications to  the plexus
choroides and the thalamus nervi optici.
  f. The anterior cerebral artery (r. cere-
bri anterior) (Fig. 9. b.) proceeds forwards
and inwards, towards the longitudinal fis-
sure which separates the anterior lobes of
the brain from each other, gradually ap-
proaching  its  fellow of the  opposite side,
with  which  it  is connected  by a  stout
transverse  branch  (ramus  communicans
anterior).  In this course, it gives small
branches to the optic and olfactory nerves,
the anterior commissure, and the adjacent
portion of the fornix and septum lucidum.
It then engages  itself in the longitudinal
fissure, between  the corresponding  lobes
of the brain, ascends until it reaches the
level of the border of the corpus callosum,
over which it is  reflected backwards and
upwards, and finally continues its course
along the entire  extent of the upper sur-
face of that body, by the side of the rapha,
and terminates at its posterior margin, by
anastomosing with the branches of the ha-
sUar  artery.   This portion  of the vessel
has been  denominated  arteria  corporis
callosi.  While traversing the upper sur-
face of that body, it distributes numerous
minute ramusculi downwards into its sub-
stance, and laterally into the internal por-
tion of the hemispheres of the brain.
  g.  The middle cerebral artery (Fig. 9.
c.)  (ramulus cerebri  medius)  is  much
larger than the  preceding, and may be
considered the terminating branch of the
internal carotid. It runs directly outwards
and backwards towards the fissure of Syl-
vius, and  distributes minute branches to
the pia mater, where that membrane  is re-
flected over the peduncle of the brain, to the
substance of the brain itself, and one branch
which plunges into the inferior horn of the
lateral ventricle, to supply the plexus cho-
roides.  The artery then enters the fissure
of Sylvius, between the anterior and mid-
dle lobes,  and after proceeding a  small
distance,  divides  into  two branches of
nearly equal  size, which,  pursuing the
course of the fissure  upwards, outwards,
and  backwards,   towards  the  superior 
ARTERIES.  (Special Anat.)
335
lateral, and posterior portion of the brain,
send off an infinity of ramifications to the
anterior and middle lobes.  These plunge
into the numerous infractuosities  of the
organ, and  after  ramifying and  anasto-
mosing  extensively  with each  other, to
form  a delicate and complicated vascular
plexus upon the pia mater, they distribute
a number of minute ramusculi into the
substance of the organ.
  Before the arteries of the posterior part
of the brain can be studied, it wdl be ne-
cessary to trace the distribution  of the
subclavian,  from which the vertebral,—
the  artery  that furnishes these vessels,
takes its origin.
  G. The Subclavian  Arteries (arteria
subclavia, dextra et sinistra) (Fig. 1. h, f.
Fig. 2. m.) occupy the  upper part of the
thorax, and  the lower lateral part of the
neck, and extend from the innominata on
the right side, and the  arch  of the aorta
on the left, over the  upper surface of the
first rib, in the interval between  the ante-
rior  and middle scalenus muscles.  The
right subclavian is a little larger than the
left, and as it arises from the innominata,
while the left proceeds directly from the
arch  of the aorta, it is shorter, more su-
perficial, and less perpendicular in its di-
rection.  Hence, while both arteries are
alike in their general arrangement, each
one  presents  some peculiarities which  it
will be important to note.  But  to render
these differences more  easily intelligible,
it will be useful to divide the trunk of the
artery into  three portions, according to
the region it occupies, as follows:—1. the
tracheal portion, extending from the ori-
gin of the vessel to the  scalenus muscles:
2. the inter-scalenar portion, comprising
that part included in the small triangular
space formed by the anterior and  middle
scalenus; and thirdly and lastly, the omo-
clavicular portion,  extending  from  the
outer limit of the scalenus muscles, to the
lower margin of  the second rib,  where
the artery descends  behind the clavicle
into the axilla, and takes the name of ax-
illary artery.   If these different portions
be examined  separately, it will be found
that the two last are exactly alike  on both
sides, but that the first presents consider-
able differences in  its situation,  course,
and relations, according as it is examined
on the right or the left.
  The right  subclavian arises  from the
innominata,  where  it  reposes  upon the
side  of the trachea, and  directly behind
the  right sterno-clavicular articulation. It
ascends with an easy sweep outwards, to
the  upper surface of the first rib, where it
glides over that bone,  and between  the
anterior and middle scalenus muscles.  In
this course, it forms a curvature, the con-
vexity of which is directed upwards  and
a  little  inwards,—the  concavity down-
wards and outwards, looking towards the
tip of the right lung, from which it is but
slightly removed.  In its transit from the
trachea to the first rib, the right subcla-
vian artery has in front the skin and pla-
tysma myoides muscle, and the superficial
fascia;  the articulation of the  sternum
with  the clavicle, the sterno-cleido-mas-
toid, sterno-hyoid and sterno-thyroid mus-
cles, the strong expansion formed by the
profound layer of the  cervical  fascia, a
plexus formed by the thyroid veins,  the
pneumogastric nerve, which descends per-
pendicularly  in front  of it in a small tri-
angular space between the carotid artery
and the internal jugular vein,—and final-
ly, numerous superficial filaments of the
sympathetic nerve.   Near the inner limit
of the scalenus muscle,  the great internal
jugular vein  also descends  in front of it,
and  the subclavian  vein is  situated in
front but  a  little lower down.   Posteri-
orly, the tracheal portion of the right sub-
clavian artery is in relation with the sym-
pathetic  nerve  and  its inferior  cervical
ganglion,  the  recurrent  branch  of  the
pneumogastric, which in coming  off from
the trunk  of the nerve is  reflected up-
wards and backwards to ascend upon the
posterior part of the  artery, and thus in-
clude  it in a kind of loop;—the longus
colli  muscle, and the transverse process
of the first  dorsal vertebra.  Superiorly
and  internally, the convexity of its arch
forms an acute angle with the carotid ar-
tery; and  interiorly  and  externally, the
concavity  of the same  curve is  directed
towards the pleura and the summit of the
right lung, with which it comes in con-
tact during inspiration.
   The  corresponding section of the left
subclavian artery, arising as it does from
the termination of the  arch of the aorta,
is much deeper seated, and is considerably
longer.  It also ascends in nearly a  per-
pendicular direction, until  it reaches the
upper surface  of the first  rib,  where  it
makes a sudden turn outwards to sweep
over that bone, between the scalenus mus-
cles.   In front of it are the sternum, cla-
vicle, and first rib, the inferior attach-
ments of the sterno-mastoid, sterno-hyoid,
and  sterno-thyroid  muscles.  The great
vena innominata, or left brachio-cephalic
vein, crosses  in front of it in a transverse
direction,—while the pneumogastric  and
phrenic  nerves  descend perpendicularly 
336
ARTERIES.  (Special Anat.)
upon  its anterior face,  inclined a little to
the right side.   Nearly parallel with this
portion of the subclavian artery, a little in
front and on the right side, the left carotid
artery, having the cardiac nerve in its vi-
cinity, ascends  to emerge from the tho-
rax ; and on the same  aspect of the ves-
sel, but a little backwards, is the oesopha-
gus.  On the  left side,  it is in relation
with the left lung and  pleura, which are
placed slightly  in advance; and posteri-
orly, it reposes upon the longus  colli mus-
cle, and the sympathetic nerve.  The tho-
racic  duct and  the  recurrent nerve also
ascend upon its posterior aspect; but the
former, after it has  reached the first dor-
sal vertebra, sweeps forwards and a little
outwards, over the upper part of the  ar-
tery, to get  in front, where it unites with
the left  subclavian  vein,  at its junction
with the left jugular.
   Thus far the subclavian artery  of the
right and that of the left side differ in im-
portant particulars in their distribution and
relations,—differences which it is essential
to bear in mind in attempting  to secure
them  in a ligature.  It will be seen, how-
ever, that both of them are so deeply seat-
ed, and so intimately connected  and asso-
ciated with  important parts,  as  to render
such an operation exceedingly hazardous;
and accordingly the  attempts which have
been thus far made to secure the subcla-
vian on  the inner side of the scalenus
muscle, have been productive of fatal con-
sequences.
   The two  outer sections of the  artery
are so nearly alike on both sides, that the
description of the right  will apply equally
well to the left.
   The second section of the artery is of
limited extent,  merely comprising that
portion of it which  is  included between
the scalenus muscles.  In its transit through
this space, it reposes upon the surface of
the first rib, over which it glides.   It is,
besides, in relation below with  the upper
portion of the right pleura, which is forced
upwards towards  the artery during  in-
spiration.  Posteriorly, it rests against the
middle scalenus muscle near its attach-
ment and in front of it  is the clavicular
attachment  of the sterno-mastoid muscle,
and the insertion of the anterior scalenus,
which has the phrenic  nerve descending
perpendicularly  in front of it, and the sub-
clavian vein crossing it upon  the same
aspect in a  transverse  direction, a little
below the level of the artery. In this re-
gion,  the  first rib furnishes  a solid point
of support against which  the artery can
be  easily compressed during operations
upon the upper extremities.
  The third portion of the artery extends
from the  outer margin  of the  scalenus
muscles to a level  of the inferior margin
of the second rib,  where  the vessel  de-
scends behind the  clavicle, and takes the
name of axillary artery.   It  is here that
its relations deserve  most  to  be  carefully
studied, because in this portion of its tran-
sit, it can be most easily exposed and in-
cluded in a ligature.  In its course, it forms
a slight curve,  the convexity of which is
upwards  and outwards,—the  concavity
downwards  towards  the  surface of  the
first and second ribs.   It traverses the in-
ferior part of the small triangle formed by
the  omo-hyoid  muscle and the  clavicle,
and is almost in contact above and a little
backwards, with the inferior chord  of  the
axillary plexus of nerves; and inferiorly,
with the  subclavian  vein, which, though
somewhat lower down, when  it  becomes
distended, sometimes ascends slightly in
front of the artery.  As the subclavian ar-
tery approaches  the  axilla,  the inferior
branch  of the axillary plexus of nerves
gets in front of it, so that the vein being
below, the artery  is  situated between it
and the nerve, but  is  a little further back-
wards at  that point  than  either.  In  its
whole course, the external third of the ar-
tery is covered in  front by the platysma
myoides and cervical fascia, a quantity of
loose cellular tissue and lymphatic glands,
and  an intricate plexus  of small  veins.
The supra-scapular artery, which  gene-
rally  advances  outwards  immediately
above the clavicle,  is sometimes situated
in front of the subclavian;  but the trans-
verse cervical is usually so far above it as
to be out of the way of any operation per-
formed upon it
  The subclavian artery does not usually
give off any branches until it arrives near
the scalenus muscle,  where it furnishes a
cluster of them, usually seven in number,
which are divided  into superior, inferior,
and external.  Of these, a part take their
origin on  the inner side  of the  scalenus
muscle,—the others,  from that portion of
the vessel which  is situated between  the
anterior and posterior scalenus, and above
the first rib.
  Superior branches, a.  R. vertebralis.
(Fig. 8. a, a, a.)   The vertebral artery is
the largest of the  branches given  off by
the subclavian.  It arises from the upper
posterior part of that artery; advances up-
wards  and a  little outwards and back-
wards, between the anterior scalenus and 
                          ARTERIES.

the longus colli muscles, and in front of
the transverse process of the seventh cer-
vical vertebra.   It then engages itself in
the foramen of the transverse process of
the sixth cervical vertebra (Fig. 8. a.),—
-   Fig. 8.
    a, a. Vertebral,  b, Posterior Cervical,  c, Subclavian.
rarely in that of the seventh, the fourth,
or the third, whence it ascends in a per-
pendicular direction, through  the canal
formed by the foramina of the  transverse
processes of all  the- vertebra  above the
sixth.  Having traversed the process of
the dentatus,  it suddenly becomes tortu-
ous, and inclines outwards, in consequence
of the greater breadth of the  atlas,  to
reach the foramen of that bone.  In order
to traverse this aperture,   it again  as-
sumes the  perpendicular  direction, and
then  takes  its course  horizontally back-
wards and  inwards, twining  round the
outer 'surface  of the  articulating  pro-
cess of the bone, and running along a
groove which exists upon its upper sur-
face.   It finally  penetrates the  posterior
occipito-atloid ligament and  the dura ma-
ter, and enters the cavity of the cranium
through the foramen magnum.  From this
point  the artery advances  upwards and
forwards, by the  side  of the spinal mar-
row, gradually converging towards its fel-
low  of the  opposite side,  with which it
unites at an acute angle, near the lower
margin of the pons varolii,  to  form the
basilar artery. (Fig. 9. d.)
   While the artery  is engaged in the ca-
nal formed by the transverse processes of
the vertebra, it distributes numerous small
ramusculi to the  adjacent muscles of the
spine, and  some which  pass  inwards,
through  the inter-vertebral  foramina  to
the spinal marrow.  Between the dentatus
and atlas, it gives off several small branches
to the deep-seated muscles,  and  one of
larger size, which  advances backwards
   \0L. II.          21)
Special Anat.)                       337

and inwards, beneath the inferior oblique
muscle, and divides  into two ramusculi.
One of these is distributed to the muscles,
—the other glides beneath the  posterior
arch  of the  atlas, and  is expended upon
the dura mater.   Several small  branches
also arise- from the vertebral  in the space
between the atlas and the occipital bone.
They are distributed  to tho recti and ob-
lique muscles, and to the adjacent portion
of the complexus. A considerable branch
advances inwards, in nearly  a horizontal
direction, between this latter muscle and
the rectus capitis posticus major, to anas-
tomose with its fellow of the opposite side,
and form a kind of arch.
   The most important  branches of  the
vertebral artery are those which it  gives
off within the cranium. They are usually
three  in number;—the posterior and  an-
terior spinal, and the inferior artery of
the cerebellum.
 a, Posterior Cerebral, o, Anterior Cerebral, c, Internal Carotid.
d, Basilar Artery, t, Inferior Cerebellic Artery. /, Superior Cere-
bellic Artery.
  o. Ramulus spinalis posterior is a small
branch, which generally proceeds from
the outer part of the vertebral, near the
corpora pyramidalia. It ranges downwards
and backwards, reaches the posterior part
of the spinal marrow, and descends paral-
lel  with  its  fellow,  near  the  posterior
groove of the chord, as low as  its termi-
nation on a level  with the second lum-
bar vertebra.   It  sends  numerous small
branches to the membranes of the spinal
chord, and minute capillary branches to
its substance.  It forms, besides, numerous
anastomoses with  its fellow of the oppo-
site side,  as well as with the branches of
the vertebral,  the  profound  cervical,  and
the intercostals.
  6.  Ramulus spinalis  anterior.   This
branch is generally somewhat larger than
the preceding.   It  arises from the inner
part of the vertebral near its termination,
—sometimes from the inferior cerebellic,
or even the basilar.  It descends in a tor- 
338                       ARTERIES. (Specie* Anat.)
tuous direction in front of the spinal mar-
row,  as  low  as the foramen magnum,
where it unites at an acute angle with its
fellow of the opposite side, to form a com-
mon trunk.  This latter descends in front
of the spinal chord, along the median line,
to the articulation of the sacrum with the
coccyx, where it terminates by  anasto-
mosing freely with the lateral sacral arte-
ries.  In its whole transit the  anterior
spinal artery distributes its ramifications to
the spinal marrow and its membranes.  It
also sends  off numerous internal and ex-
ternal branches,  which anastomose in the
same manner as the ramifications of the
posterior spinal.
  y. Ramulus cerebelli  inferior (Fig. 9.
e.) is usually the last branch given off by
the vertebral before its termination, and
sometimes arises from the basilar.  It pro-
ceeds outwards across the pyramidal body
of the medulla oblongata, and in the space
between the radicles of the pneumogas-
tric  and  the spinal accessory nerves.  In
most cases, it divides, near its origin, into
two branches,—one internal and the other
external, which  sometimes indeed  have
an  independent  origin.   The first winds
round  towards  the posterior part of the
medulla oblongata, sends numerous small
branches to the plexus choroides of the
fourth ventricle, and terminates about the
vermiform  process.   The  second sends
small ramifications to the radicles of the
eighth and  ninth pair of nerves, pursues
a tortuous direction outwards and down-
wards upon the lower surface of the  cere-
bellum (Fig. 9.), and is extensively dis-
tributed Upon the pia mater and in the in-
fractuosities of the organ. It anastomoses
freely with  the superior cerebellic artery.
  8. Ramulus basilaris. (Fig. 9. d.) This
artery, it has  been already  mentioned, is
formed by the  union of the two vertebrals.
It commences at the posterior margin of
the pons varolii, where  this joins the me-
dulla oblongata.  It proceeds directly for-
wards, between the sixth pair of nerves, and
along the groove which occupies the lower
surface of the pons varolii. Having reached
the  anterior border of this  latter body, it
divides in the vicinity of the crura cerebri
into two branches, which  separate  from
each other at an obtuse angle.
  The basilar artery sends many small
ramifications to the  pons varolii  and me-
dulla oblongata; the origin of the  adja-
cent nerves, and to the pia mater. It also
gives origin to the superior  cerebellic  ar-
tery, which goes to the upper part of the
cerebellum.
  t. Ramulus cerebelli superior,  s. ante-
rior. (Fig. 9. /.) The superior cerebellic
artery arises from the basilar near its ter-
mination, whence it winds round beneath
the peduncle of the cerebrum and the pons
varolii, to ascend upon the upper surface
of the cerebellum near the tubercula quad-
ragemini.  It sends branches to the pe-
duncles,  pons varolii, tubercula quadra-
gemini, pineal gland, and valve of Vieus-
sens, and then  running in a tortuous di-
rection outwards and  backwards, divides
into two  orders of ramifications.  The first
follow  the upper surface of the  cerebel-
lum to its posterior  margin, supplying the
pia  mater and the plates of the organ, and
terminating by forming a free anastomosis
with the inferior cerebellar artery.  The
others  are in part distributed to the ante-
rior part of the cerebellum, while some
of them  ascend upon the  posterior lobes
of the cerebrum.  A branch of this artery,
—sometimes of the basilar itself, is distri-
buted to the labyrinth of the ear, which it
reaches through  the  internal auditory fo-
ramen,  in  company with the  auditory
nerve.
  f. Ramulus cerebri posterior.  (Fig. 9.
a.)   The basilar artery having reached
the space between the  pons  varolii  and
the mammillary bodies,  terminates by di-
viding into two symmetrical branches,
which are distributed to the posterior lobe
of the  cerebrum.   The posterior cerebral
artery, thus taking its origin, winds at first
forwards and outwards beneath the pedun-
cle  of the brain, and then backwards, hav-
ing the common motor nerve between it
and the  vessel last d embed.   It finally
reaches the inferior surface of the^ioste-
rior lobe  of the cerebrum, ramifies mi-
nutely upon the pia mater, and in the in-
fractuosities of the organ, and distributes
minute capillary branches to its substance.
Near its origin,  it sends branches to the
crura of the brain, the mammillary bodies,
tuber cinereum, and the pons varolii.  It
also sends a branch into the third ventri-
cle, to supply the thalamus, striated body,
the anterior pillars of the fornix, and the
plexus choroides.  Near the motor nerve,
its  anterior convex surface receives the
communicating branch  from the internal
carotid, which  thus completes the circle
of Willis.   Beyond this  point,  it sends
other branches to the pons varolii, the cor-
nu  ammonis, tubercula quadragemini, pi-
neal gland, and thalamus.
  The union which is formed  between
the posterior cerebral arteries and the in-
ternal  carotids,  completes a circle of an
irregular shape, which occupies  the base
of the brain, and circumscribes the mam- 
ARTERIES.  (Special Anat.)
339
miliary bodies, the  tuber  cinereum, and
commissure of the optic nerves.
   b. Ramus thyroideus inferior. (Fig. 2.
n.)  The interior  thyroid  artery  varies
much in size,  according to the number of
branches to which it gives origin.  In the
foetus, when  the  thyroid  gland is very
large,  it almost  equals the subclavian
itself: and in the adult, when besides the
thyroid proper, and the ascending cervi-
cal,  it supplies the  supra-scapular and
transverse cervical, it is very large, and
represents a short thick stump, from which
a switch of branches proceeds.  It  arises
from the upper part of the subclavian, im-
mediately on the outer side of the verte-
bral, but a  little  more forwards.  The
trunk of the inferior thyroid is placed per-
pendicularly upon  the  internal margin of
the anterior scalenus muscle, but does not
ascend  far before  it divides  into  two
branches,—the  inferior thyroid proper,
and the ascending cervical.
   a. Ramulus thyroideus inferior propri-
us. (Fig. 2. n.) This branch, proceeding
from the common trunk, inclines upwards
and inwards, behind the carotid artery and
pneumogastric nerve, and in front  of the
vertebral artery and the longus colli mus-
cle.  In its course, it gives branches to
this muscle, and others to the trachea and
oesophagus, which descend into the tho-
rax, and anastomose  with the  bronchial
artery.  The inferior thyroid finally reaches
the external border of the  thyroid gland,
ramifies very  extensively through the
whole of its  inferior  part, and forms a
most complex anastomosis  with the thy-
roid branch of the  external carotid.
   /3. Ramulus cervicalis ascendens. (Fig.
2. o.)  The ascending cervical ramulus
takes its origin from the posterior part of
the inferior thyroid, where it  changes its
direction—sometimes from the subclavian
itself, or the  internal  mammary.  It as-
cends in front of the transverse  processes
of the cervical vertebra, between the rec-
tus capitis anticus, and the scaleni mus-
cles, gradually inclining backwards as it
advances, and  terminates about  the level
of the first or second cervical vertebra, by
dividing into two branches.  One of these
passes towards the posterior  part  of the
transverse processes, and supplies the tra-
chelo-mastoideus and the oblique and recti
muscles upon  the back of the neck, where
it anastomoses with the occipital, verte-
bral, and posterior or profound cervical ar-
teries.  Some of its terminal ramifications
penetrate between the first and second
cervical vertebra, and are expended upon
the membranes of the spinal marrow. The
other branch inclines outwards, and is dis-
tributed to the complexus, and the poste-
rior part of the digastric muscle.
   In its course, the ascending cervical ra-
mulus gives branches outwards to the sca-
leni, levator scapulae, and trapezius mus-
cles;  forwards to the mastoid;  and in-
wards to the glands of the neck, the eighth
pair of nerves, the cervical ganglion  of
the sympathetic,  and. several which pass
with the cervical nerves through the in-
tervertebral foramina, to  be distributed
upon the  membranes of the spinal mar-
row, where  they  anastomose freely with
the spinal ramusculi  of  the vertebral ar-
tery.
  y.   Ramulus   cervicalis  superficialis.
(Fig. 2. p.)  The superficial cervical ra-
mulus, which is very constant in its exist-
ence, has been very carelessly described
by anatomists, some of them representing
it as a  distinct branch, others confounding
it  with the  transverse  cervical, while
many have omitted it altogether,  it gene-
rally arises  from  the inferior thyroid ar-
tery, but sometimes  from the  ascending
cervical, and  occasionally from the sub-
clavian. It proceeds outwards, backwards,
and a little upwards, in front of the ante-
rior  scalenus  muscle, beneath the omo-
hyoideus,  and in front  of  the  brachial
plexus  of  nerves.   It finally  glides  be-
neath  the  trapezius, sends ramusculi to
that muscle and  the levator scapula?, and
terminates by numerous small branches
which  are distributed to the supra-spinatus
muscle, and the  rhomboideus  major and
minor.  Some  of the latter descend for
some distance along the  base of the sca-
pula. The superficial cervical artery gives
off, in its  course, small branches to the
mastoid and scaleni muscles; one or more
to the brachial  plexus  of nerves; and
several, of small size, to the glands and
other structures which occupy  the supra-
clavicular region.
   External branches,  a.  Ramus scapu-
laris superficialis, s. transversus scapula,
s. scapular is superior. (Fig. 2. q.)  This
is a considerable branch,  which arises per-
haps more  frequently from  the inferior
thyroid than from the subclavian itself.  It
also  takes  its origin, in some  instances,
in common with  the transverse cervical,
or even from the  internal mammary.   In
either  case, it commences upon the inner
side  of the  scalenus muscles, and is  co-
vered by the sterno-cleido-mastoideus.  In
this situation,  it sends small branches  to
these muscles, and to the sterno-hyoideus
and sterno-thyroideus.  It  then proceeds
directly outwards, either in  front or be- 
340                       ARTERIES.  (Special Anat.)
hind  the scalenus anticus, and  a little
above and posterior to the clavicle, paral-
lel with  which it  runs throughout its
whole course.   Having reached the mar-
gin of the trapezius  muscle, it glides be-
neath it, until it arrives in the  vicinity of
the  coracoid  process,  where  it  reposes
close upon the scapula, and is merely sepa-
rated from  the supra-scapular nerve by
the coracoid ligament,  which, with  the
notch of the scapula, completes the fora-
men  through  which the  nerve  passes,
while the artery glides over the  surface
of the ligament.  The  artery  here gives
off several branches, which ramify upon
the  capsular  ligament  of  the shoulder-
joint, and in the upper anterior portion of
the deltoid muscle, forming a free anasto-
mosis with the anterior circumflex. It also
sends a branch backwards, along the supra-
spinal fossa, to  supply the  supra-spinatus
muscle, and others to the trapezius.  The
continuous or terminal portion of the vessel
(Fig. 10. e.), then glides along the neck
of the scapula,  beneath the arch formed
by the spine,  to reach the  infra-spinal
fossa, where it ramifies extensively in the
infra-spinatus, teres minor and  major, and
anastomoses posteriorly with the posterior
scapular branch of the  transverse cervi-
cal,  and anteriorly with the  circumflex
branch of the subscapular artery.  In its
course,  the supra-scapular artery distri-
butes minute branches  to  the glands of
the neck, and the plexus of nerves.
   b. Ramus transversalis colli, s. scapu-
laris  posterior  (Fig. 2. r.  Fig. 10. b.) is
generally larger than the preceding.   Its
most  common origin is from the subcla-
vian, immediately on  the inner side of the
scalenus muscles, or where  that artery re-
poses between  them.  Sometimes, how-
ever, it is a branch of the inferior  thyroid,
and in some instances it arises by a com-
mon trunk  with the supra-scapular.   It
proceeds outwards  and backwards, across
the triangular space  of the neck formed
by the sterno-mastoid and trapezius mus-
cles,  and  the  clavicle.   In  its  transit
through  this region,  it glides over the
brachial  plexus of nerves, — sometimes
through it,—passes beneath the trapezius
and levator scapula?,  and having  arrived
at the angle of the scapula, descends in
nearly a  perpendicular direction upon the
back, along the base of that bone, covered
by the rhomboid muscles, and  terminates
by numerous ramifications, which are spent
upon the neighbouring muscles, in the vi-
cinity of the inferior scapular angle.
   In its  course, the  transverse cervical
artery first gives branches to the  scaleni
muscles, to the plexus of nerves, and *
the glands and integuments of the neck
It sends several considerable branches to
the trapezius and levator scapula; -muscles.
Near the angle of the scapula, it gives oft
a large branch which  immediately subdi
vides; one branch advancing forwards and
outwards in  the supra-spinal fossa, is dis-
tributed  to the supra-spinatus  and trape-
zius ;—the other twines over the posterior
surface of the angle of the scapula, and
descends upon its dorsum, as  low as the
root of the spinous process.  The continu-
ous trunk of the artery, which is properly
entitled to the appellation of posterior sca-
pular  (Fig. 10. &.),  descends  along the
                Fig. 10.
 b, Posterior Scapular,  e, Circumflex of the Subscapular, d, Pos-
terior Circumflex, e, Superior Scapular.
base of the scapula, covered by the rhom-
boid and trapezius  muscles, to which it
sends numerous branches, and in its course,
distributes a great number of ramifications
to the serratus major anticus, serratus su-
perior posticus, and latissimus dorsi.
   Posterior branches,  c.   Ramus cervi-
calis posterior, s. profundus.  (Fig. 8. b.)
This  is  a small  deep-seated branch, not
very regular in its origin. It most usually
proceeds  from the  posterior  part of the
subclavian, where it reposes between the
anterior and middle  scaleni muscles; but
sometimes from the  inferior thyroid, the
vertebral, or even  the superior intercostal.
It immediately twines outwards and back-
wards in the space between  the transverse
processes of the  sixth and seventh  cer-
vical, or  the  seventh  cervical and  first
dorsal vertebra, to  reach their posterior 
aspect.  From this point it ascends in the
space between the spinous and transverse
processes, sending branches to the scaleni,
rectus capitis,  intertransversaria,  trans-
versalis cervicis, semispinalis cervicis, and
complexus muscles; and others which tra-
verse the  intervertebral foramina, to be
distributed to the membranes of the spinal
marrow.  It terminates by several small
branches, which supply  the  deep-seated
muscles about the upper part of the neck,
and one of considerable  size,  which anas-
tomoses with a branch of the occipital.
   Inferior branches, a. Ramus mamma-
rius internus, s. sternalis.  (Fig. 11. a, a.)
                 Fig. 11.
a, a, Internal Mammary, b, Superior Intercostal, e, Subclavian.
The internal mammary artery comes off
from  the lower part of the  subclavian,
nearly opposite the origin of the inferior
thyroid,—sometimes a little  further in-
wards.   It descends behind  the  cartilage
of the first rib,  and is crossed by the phre-
nic nerve  in an oblique direction, as the
latter passes from  its  outer to  its inner
side.  From the first rib,  it descends upon
the posterior surface of the  succeeding
ribs and the intercostal muscles, as low as
the space between the sixth and seventh,
and glides between them and the triangu-
laris sterni muscle. Above, it is about a
finger's breadth from the margin of the
sternum,  but lower down  it  inclines to-
wards the ensiform cartilage,  and ap-
proaches its fellow of the  opposite side.
In  the space between the sixth and sev-
enth ribs, it divides into  two branches, by
which it terminates.  The  first,  r. mus-
culo-phrenicus, s. diaphragmaticus,  in-
clines outwards,  along the  posterior sur-
face of the cartilages of the  false ribs, dis-
tributes  numerous small branches to the
diaphragm, passes between  its digitations,
and is finally distributed  to the transverse
And oblique muscles of the abdomen, where
it anastomoses  with the  inferior intercos-
tals, the superior lumbar, and  the  circum-
flexus ilii.   The second, r. abdominalis, s.
                  29*
ARTERIES.  (Special Anat.)                      341

               epigastricus superior, descends behind the
               rectus muscle, sending ramusculi into  its
               substance, as low as the umbilicus, where
               it terminates by anastomosing  with the
               epigastric artery.  This branch, and some-
               times the trunk itself, sends a small branch
               inwards, which ranges across the poste-
               rior face of the ensiform cartilage to an-
               astomose with a similar one from its fel-
               low.  From this, a small ramusculus fre-
               quently  descends  in the suspensory liga-
               ment of the liver, to anastomose with the
               hepatic artery.
                  Besides  these terminal branches, the
               internal mammary supplies many others
               in  its course.   Near its origin, it sends
               some to the sterno-hyoid and sterno-thy-
               roid muscles,  to the lymphatic glands
               about the root of the neck,—one or more
               to  the  bronchia, r. bronchialis superior,
               and to the  remains of the thymus gland,
               —also to the anterior mediastinum.  This
               latter branch, r. mediastinus  anterior, is
               frequently of considerable size, and divides
               into two ramusculi, one of which ascends
               towards the neck, and sends  some of its
               ramifications  to the thymus  and thyroid
               glands; while the other ascends  in  the
               anterior mediastinal space, and distributes
               its branches to the pericardium, the peri-
               osteum  of the sternum, and the adjacent
               portion  of the pleura.   While  it  is still
               high up in the thorax, the internal mam-
                mary gives off a branch, r. diaphragmati-
                cus  superior,  s. comes  nervi  phrenici,
                which descends in the course of the phre-
                nic nerve, distributes numerous ramusculi
                to the pericardium and the parts contained
                within  the anterior mediastinum, and is
                finally expended upon the anterior middle
                part of the diaphragm, where it  anasto-
                moses  extensively with the  inferior  dia-
                phragmatic or phrenic artery.
                   As the  artery descends behind each in-
                tercostal space, it gives off a series of ex-
                ternal   and internal branches,  generally
                corresponding in number to  the number
                of spaces  over which it glides.  They are
                denominated anterior  intercostals, r. in-
                tercostales anterior.  Each of the external
                branches  takes  its course  along the infe-
                rior margin of the corresponding rib, first
                beneath the pleura, then between  the in-
                ternal and external intercostal muscles, to
                 which it sends numerous small branches.
                 It finally anastomoses with the posterior
                 intercostal artery of the  same space sent
                 off by the aorta, and sends several small
                 branches  forwards, which perforate the
                 external intercostal muscle, and supply
                 the  pectoraiis  minor  and major, and the
                 mammary  gland,  and anastomose freely
                 with the thoracic branches of the axillary. 
342                       ARTERIES. (Special Anat.)
The internal branches ramify extensiv ely
upon the periosteum of the posterior face
of the sternum, and in the cellular tissue
of the anterior mediastinum, where  they
form  a free anastomosis with  the vessels
of the opposite side.  Some of them perfo-
rate the intercostal muscles near the  mar-
gin of the sternum, and are distributed to
the muscles on the outer part of the thorax.
   The  external  branches are larger  as
they are lower down, while the  internal
are  larger  above,  and smaller  below.
Sometimes a small branch takes its course
along the upper margin of each rib.
   b. Ramus intercostalis superior. (Fig.
11. 6.)  This branch varies much in  size,
according as it supplies on£ or more inter-
costal spaces.   It usually arises from the
posterior part of the subclavian,  a little
exterior to the origin of the internal mam-
mary, and  immediately on the inner side
of the  scalenus  muscle.  Sometimes it
comes off in common with  the  profound
cervical, the internal mammary,  or even
the  inferior thyroid.  From its origin, it
advances  downwards  and outwards,  in
front of the neck of the first rib,  and if it
supplies more than  one intercostal space,
in like manner in front of the second or
even the  third rib, as  the case  may be.
Having  reached the  intercostal space,
it divides  into  posterior  and   external
branches.  The first r. dorsales,  proceed
backwards, and divide into two series  of
branches, one of which penetrates the in-
tervertebral foramina to be distributed to
the spinal marrow, where they anastomose
with the spinal branches of the vertebral;
the others advance directly backwards be-
tween the necks  of the ribs, and are dis-
tributed to the deep-seated muscles of the
back.
   The external  branch,  r. intercostalis,
advances outwards along the  lower  mar-
gin  of the rib, between the internal and
external intercostal  muscles,  and  after
proceeding a  short distance, divides into
a superior  and an  inferior branch.  The
first follows the  inferior, the  second the
superior, margin of the ribs between which
they are  placed,  supply the  intercostal
muscles, and form a free" anastomosis with
the posterior intercostals, and with the su-
perior intercostal branch of the  internal
mammary.  If more than one intercostal
space is supplied by this artery,  the sec-
ond branch pursues  precisely the same
distribution.
   Sometimes the superior intercostal fur-
nishes branches  to the oesophagus and
bronchia; and very generally it distributes
small ramifications to the posterior medi-
astinum and the bodies  of the  vertebra.
  Varieties of the Branches  of the Sub-
clavian Artery:
  Several of the most important anoma-
lies of the origin of the subclavian artery
have  been described above.  It only re-
mains, therefore, to consider  those which
are most frequently observed in its seve-
ral branches.
  The vertebral artery very often departs
from  the origin and distribution detailed
in its description.  The most common of
these varieties  is the origin of the  left
vertebral from  the arch of the aorta, be-
tween the left carotid and left subclavian.
The  right vertebral seldom  arises from
the arch of the aorta, and scarcely ever,
except where  the left presents a similar
condition.  Sometimes, however, it pro-
ceeds from the  angle of the bifurcation of
the innominata. (Meckel.)  Occasionally
the left vertebral artery takes its origin
from the aorta, beyond the point at which
the left subclavian is given off.  (Meckel,
Handbuch der Path. Anat. II. 109.  Wins-
low.) Sometimes it arises from the aorta
on the right side, in common with the in-
ferior thyroid. (Walther, Loder.) Cases
in which both  vertebrals  proceeded from
the arch have been noted by  Penada, Fi-
orati, and Meckel.  In a few instances,
the right  subclavian  and right carotid
arise  from the arch, having the right ver-
tebral between them, while the left verte-
bral arises in a similar manner between
the left carotid and the  left subclavian.
(Tiedemann,  Muller.)   A  much more
rare anomaly  is that  in which the verte-
bral artery  is double.  Examples of  this
kind have been observed by Hebenstreit,
Henkel,  Huber,  and Meckel. In  the
cases described by Henkel  and Huber,
one branch proceeded from the  arch—the
other from  the subclavian at  the  usual
point. In both instances, the anomaly was
on the left side.  In Huber's  case,  the
normal branch was smaller than the other,
with which it united, however, on a level
with  the  fifth  cervical vertebra, and en-
tered the aperture in the transverse  pro1-
cess of that bone.  In the example of this
anomaly reported by Henkel, one of the
two vertebrals  which existed on the same
side, entered the transverse process of the
seventh—the other that of the eighth  cer-
vical  vertebra.   In one case observed by
Meckel, there were two vertebral arte-
ries on the right-side, both of which  pro-
ceeded from the subclavian.  One of thein
penetrated the  aperture in the transverse
process of  the sixth  cervical  vertebra,
while the other entered that  of the third.
(Handb. der Path. Anat. II. 111.)   Otto
reports a case in which the right vertebral 
ARTERIES.  (Special Anat.)
343
artery was preternaturally small, and en-
gaged itself in the transverse process of
the fourth cervical vertebra, the fifth, sixth,
and seventh processes presenting no  fora-
mina.  In  another instance observed by
the same gentleman, the upper part of
the vertebral artery was transfixed by the
hypoglossal nerve.  (Lehrbuch der Path.
Anat. I. 309.)   A case still more  singu-
lar has been described by Albert  Meck-
el.  There  were three  vertebral arte-
ries  on  the right  side,  two  of  which
proceeded  directly  from the  subclavian,
while the  third had its origin from  that
vessel in common with the inferior  thy-
roid. They all united into a common trunk
about the  middle of the  neck, which en-
tered the transverse process  of the fourth
cervical  vertebra. (Meckel.  Archiv. fur
Anat. und Physiol. 1828. p. 170.)  When
there are two vertebral branches on one
side, the smaller, after ascending for some
distance, plunges directly into  the  ver-
tebral canal, through  the intervertebral
space. (Meckel.)
   The vertebral artery when single,  ordi-
narily enters the transverse process of the
sixth cervical vertebra, but  it may pene-
trate below or above this point.  In some
instances,  but  very  rarely,  it engages
itself in  the seventh. (Portal.)  Oftener
it penetrates the  transverse processes
higher up.   It is frequently observed en-
tering the fifth.  Eustachius saw it pene-
trating the fourth; Haller the third; and
Soemmering remarks  that  it sometimes
engages itself in this bony canal as high
as the  transverse process of the  second
cervical vertebra.  In one instance, Burns
saw it ascending to the level of the lower
margin of the thyroid cartilage, before  it en-
tered the transverse processes. (Barclay.)
   Meckel remarks, that in two instances
he saw the basilar artery divided into two
branches, which, after advancing  a  short
distance, united with each other, thus cir-
cumscribing a small insular space.   This
anomaly he thinks must be  rare, and it is
worthy of observation, that in  both the
bodies in which it was observed, a similar
Bcission  of the anterior communicating
branch   of the  internal  carotids existed.
Huermann has reported a case, in which
the  vertebral arteries were  united  by a
transverse  branch,  a  little below where
they join to form the basilar artery. (Meck-
el.)  In a  case figured by  Tiedemann
(Tab. viii. fig. 3.), the right vertebral was
preternaturally small; the posterior infe-
rior cerebellic artery of the left side was
larger than that of the  right; while the
anterior inferior artery of the cerebellum,
on the  right side, was much larger than
that on the  left,—the latter being repre-
sented by several small branches.
  The inferior thyroid is subject to many
anomalies in  its origin.  Sometimes  it
arises from the common carotid. (Nicolai,
Haller, Vink, Bohmer, Neubauer, Hu-
ber, J. F. Meckel, Sen. and Jun., Tiede-
mann.)   Neubauer and Meckel report a
case in which it arose on the right side,
from the arch of the aorta, between the
innominata and the left carotid. Barclay
met with an example in which both infe-
rior thyroids proceeded from the aorta by
a common trunk, and the left branch pass-
ed obliquely across the trachea, where it
would  have  been divided in tracheotomy.
Sometimes it consists of a single branch,
which  proceeds directly to the  thyroid
gland, the branches which are usually fur-
nished by the thyroid axis to the neck be-
ing supplied by  the subclavian.   Some-
times the artery on one side is  nearly ob-
solete (Haller), or it  may be entirely
wanting (Burns, Green).  It may arise in
common with the internal mammary,  or
the superior intercostal; or there may  be
a third inferior thyroid artery (arteria thy
roidia ima,  s. Neubaueri),  which  either
arises from the arch of the aorta, the in
nominata, or the primitive carotid.  I have
seen this anomaly,  in several instances,
under all these forms.  It was  first noted
by Neubauer, and has since been observed
by several anatomists, and by Godman.
  The  supra-scapular  artery, which  is
generally a branch  of the  thyroid axis,
sometimes proceeds from  the  subclavian
or the transverse cervical.  It passes some-
times in front—sometimes behind the sca-
lenus anticus.
   The ascending cervical is sometimes a
branch of the  subclavian, or the  internal
mammary.
   The profound cervical,  in  a  few  in-
stances, arises from the inferior thyroid,
the superior intercostal, or even the ver-
tebral.
   The transverse cervical may arise either
from the subclavian  or the thyroid axis.
   The internal mammary artery not un-
frequently arises by  a common trunk with
the  superior  intercostal.   Sometimes it
arises in common with the inferior thy-
roid (Meckel, Green),  and in rare  in-
stances, from the innominata (Neubauer),
or  directly  from the  arch  of the aorta
(Bohmer).
   The superior  intercostal artery some-
times  arises in common with the internal
mammary—rarely from the inferior thy-
roid (Soemmering), and in some instances
from  the profound  cervical.   Green ob-
served  one  case in which it proceeded 
344                       ARTERIES.  (Special Anat.)
from the thoracic aorta.  The varieties in
its distribution have been already noted.
  H.  The Axillary artery, arteria axilla-
ria (Fig. 2. s, t.) is the  continuation of
the subclavian, and according to the divi-
sion made above, extends from the inferior
margin of the second  rib, to the termina-
tion of the  fold of the axilla, or  a  level
with the attachment of the latissimus dorsi
and teres major muscles.  The  course of
the artery, in its transit through the axil-
lary region, is downwards, outwards, and
backwards; and when the arm is by the
side,  it forms  a gradual curve, having its
convexity upwards and outwards,—its con-
cavity downwards and inwards.  The re-
lations  of the vessel  are very complex
throughout  its whole  extent, and should
be  carefully studied.
   Where the artery is about to leave the
side of the  thorax, it reposes upon the in-
tercostal muscle and  the  superior attach-
ment of the serratus magnus.   The axil-
lary vein is in front  of it, and  when col-
lapsed, a little beneath  its  level;—the
brachial plexus of nerves is behind, and a
little above.  Accompanied  by the  vein
and nerves, it glides outwards  through a
small triangular space, bounded internally
by the walls of the thorax, superiorly by
the clavicle or  subclavius muscle, exter-
nally  by the  pectoraiis  minor,—and  is
covered in  front by a lunated aponeurotic
expansion, which extends from the ribs to
the clavicle and coracoid  process, denomi-
nated costo-coracoid   ligament,—also by
the pectoraiis major muscle.   Having tra-
versed this space, it glides behind the pec-
toraiis  minor, a little below the point at
which  it becomes tendinous, still having
the vein  in front but lower down, while
the several chords  which form the bra-
chial plexus of nerves interlace upon its
surface, so as to form around it a kind of
nervous sheath.   Finally, after emerging
from beneath  the pectoraiis minor, it con-
tinues  its course  outwards, reposing pos-
teriorly upon the  subscapularis muscle,
which  separates it from the capsular liga-
ment of the  shoulder joint,  and  courses
along in front of the  attachments of the
latissimus dorsi and  teres major, until it
reaches the level of  their outer margin,
where it takes the name of brachial or
humeral  artery.  In this  part of its tran-
sit, the artery has the same relations with
the vein  as above.  The two radicles of
the median nerve, where they approach
to unite with each other in front of the
 vessel, have  the latter  placed between
 them, one radicle of the nerve being on
 its radial, the other  on  its ulnar aspect.
 The  external cutaneous nerve  is  also on
its radial side, as is likewise the coraco-
brachialis muscle.  The internal cutane-
ous follows  its ulnar side, and  the  radial
and  circumflex  nerves gradually recede
from it as they advance backwards. After
the artery glides over  the  surface of the
subscapularis muscle, it courses along the
margin of the  coraco-brachialis muscle,
and  upon  the surface of the  humerus,
where, being superficially situated, it can
be compressed  against that bone.  (See
Arm.)
  While  coursing through  this region,
the axillary artery furnishes branches to
the muscles of  the thorax, the shoulder,
and upper part of the arm, and the fat and
glands in the axillary space.
  From its internal part  there are gene-
rally three  or  four branches  given off,
which are denominated thoracics, r. tho-
racica.
  a.  Ramus  thoracico-acromialis.  (Fig.
2. u.)  This is generally a branch of con-
siderable  size, but varies much in this re-
spect, according  as   the  other  thoracic
branches take their origin from it or from
the axillary.  It arises from the anterior
part of the axillary artery, immediately
on the inner side of the pectoraiis minor,
and divides directly into several branches,
which  proceed  in different  directions.
Some of these,  of small  size,  are  distri-
buted inwards, upwards, and forwards, to
the  serratus magnus  and  intercostal mus-
cles, the subclavius,  and the  pectoraiis
major.  The  main branch advances out-
wards, upwards, and  backwards, towards
the space which separates the deltoid from
the  pectoraiis major, and in front  of the
pectoraiis minor.   It  divides into an as-
cending and a  descending branch.   The
first advances towards the acromion pro-
cess, sending small branches  to the in-
teguments of  the shoulder and  the deltoid
muscle, — a branch  which  follows the
course of the clavicle  to its outer articula-
tion,—and finally, several small branches,
which plunge profoundly  beneath the del-
toid and the  acromion process, and anas-
tomose extensively upon the shoulder joint
with the suprascapular,  and  circumflex
arteries.  The descending branch pursues
the course of the cephalic vein, and is ex-
pended upon the  deltoid and pectoraiis
major.
  The thoracico-acromialis often gives off
all the thoracic branches, and when  it
does so,  it originates by a stout  trunk,
which immediately divides into a leash of
branches.
   b.  Ramus  thoracieus supremus  (Fig.
2. v.) is generally a small branch, which,
when it does not arise from the thoracico- 
ARTERIES.  (Special Anat.)
345
acromialis, comes  off from  the  axillary,
near the  inner margin of the pectoraiis
minor.   It descends in the space between
this muscle and the pectoraiis major, send-
ing branches to both, and to the  cellular
tissue between them,  and likewise to the
serratus magnus and  intercostal muscles.
These branches anastomose with the in-
ternal mammary and  intercostal arteries.
  c. Ramus thoracieus longus, s. exter-
nus. (Fig. 2. w.) This branch, sometimes
denominated external mammary, is larger
than the  preceding,  with  which it fre-
quently takes its origin.   In most cases,
however,  it arises from  the  axillary  be-
hind the  pectoraiis minor muscle, along
the outer  margin of which it descends, be-
tween the pectoraiis major and the serra-
tus magnus, gradually inclining inwards
towards the side  of the thorax.   It sends
branches to all these muscles, to the sub-
scapularis, and glands and fat of the ax-
illa, and finally to the intercostal muscles
and mamma, where it anastomoses with
the internal mammary artery.
  d. Ramus thoracieus alar is.  This is
merely a  small irregular branch, which,
when it exists, arises near the middle of
the axilla, or comes off from some of the
other thoracic branches.  It is distributed
principally to the glands, and cellular  tis-
sue of the axilla, and to the adjacent mus-
cles.
  The axillary artery having reached the
outer edge of the subscapular muscle,
gives off from  its lower part a  large
branch,  denominated
  e. Ramus subscapularis  (Fig. 2. x.),
which  is  the largest of the vessels  to
which it gives origin.   It descends about
an inch  parallel with the inferior costa of
the scapula,  accompanied  by its corre-
sponding vein, and after giving off several
small ramifications to the glands and cel-
lular tissue of the  axilla, and the subsca-
pularis muscle, divides into a descending
and a posterior branch.
  The first pursues the original course of
the artery, and  descends along the lower
margin  of the subscapularis muscle,  to-
wards the inferior angle of the scapula,
sending numerous  ramuli  into its  sub-
stance.  It distributes, besides,  branches
of considerable size to the serratus mag-
nus and latissimus dorsi,—small ones to
the glands and cellular tissue,—and near
the angle of the scapula,  several are re-
flected backwards over the margin of the
bone, to the teres minor and major, and to
anastomose  with the  ramifications  of its
posterior branch, and  the transverse cer-
vical.
   The posterior branch, ramulus circum-
flexus scapula, is larger than the preceu-
ing.  It is reflected backwards, and turns
round  the lower margin of the neck of
the scapula, in the space between the long
head of the triceps, the latissimus dorsi
and teres major, and the teres minor.  It
gives branches  to the  subscapularis,—one
of considerable  size to the latissimus dorsi,
and others to. the triceps, and teres major
and minor.  Having reached the posterior
part of the scapula, it takes the name of r.
dorsalis scapula (Fig. 10. a), and divides
into a superficial and a deep-seated branch.
The first glides between the integuments
and teres minor muscle, and supplies the
superficial parts.  The second  runs pro-
foundly between the  infra-spinatus mus-
cle and the bone, and ramifies extensively
upon the dorsum of the  scapula,  anasto-
mosing  posteriorly with the posterior sca-
pular artery, and inferiorly with  the re-
flected ramifications of the subscapularis.
It sends a considerable branch upwards,
beneath the acromion process, into the
fossa supra-spinatus,  which anastomoses
freely with the supra-scapular,  the trans-
verse  cervical,  and  the thoracico-acro-
mialis.
  Still lower down,  the axillary artery
gives off the anterior and  posterior cir-
cumflex branches.
  f. Ramus circumflexus posterior. (Fig.
12. b. Fig. 10. d.) The posterior circumflex
branch is larger than the anterior. It gene-
rally arises from the  axillary artery just
below the head  of the  humerus,  but some-
times it is a branch of the subscapular, the
superior profunda of the brachial, or of the
anterior circumflex.   Taking its  course
directly backwards, it twines around the
upper part  of the humerus, between the
long head of the triceps and the bone, and
through the space between the teres mi-
nor and major.   It gives small ramuli to
all these muscles, and having reached the
posterior part of the arm, divides into as-
cending and descending branches.  The
first ascend over  the attachment of the
teres  minor, towards the  acromion pro-
cess, and after sending numerous branches
to  the  deltoid, ramify  extensively upon
the capsule of the joint, and anastomose
with the thoracico-acromialis. The second
descend towards the tendon of the deltoid,
and after supplying that muscle,  anasto-
mose with the  circumflexus anterior, and
the profunda superior.
   g. Ramus circumflexus anterior. (Fig.
12. a.)  Smaller than the  preceding, the
anterior circumflex artery usually arises
a little lower down.   Sometimes, never- 
346                       ARTERIES.  (Special Anat.)
Fig. 12.
theless, it comes off in common with it,
and occasionally it arises from the subsca-
pular, or the profunda humeri.   It twines
round in front of the bone, adhering inti-
mately to its surface, beneath the coraco-
brachialis and the short head of the biceps,
and advances beneath the deltoid. It sends
numerous ramuli  to these muscles, and
to the subscapularis.  Near the bicipital
groove of the humerus, it divides into as-
cending and descending branches. Of the
■former, the greater part  are spent upon
the  capsular  ligament of the  shoulder
joint where they ramify  and anastomose
with the posterior circumflex, and the tho-
racico-acromialis.   A  few small ramuli,
however, follow the course of the bicipital
groove,  and supply  the  synovial mem-
brane. The descending ramuli pass down-
wards beneath the  deltoid, supplying its
substance, and anastomose below with the
profunda superior and posterior circumflex.
   I.  Arteria brachi-
alis, s. humeraria. At
the  lower  border of
the  latissimus dorsi,
the  axillary takes the
name of brachial ar-
tery, which is there-
fore merely a contin-
uation  of  the great
trunk  already   de-
scribed.   From  this
point, the vessel pur-
sues a spiral  course
down the arm, inas-
much as where it ap-
proaches the  elbow,
 it   gradually  winds
 forwards to reach the
 middle  part  of  the
 anterior face  of  the
 bend of the fore-arm.
 Throughout  its  en-
 tire course, it reposes
 so  close   upon  the
 bone, that  it can be
 easily commanded by
 pressure.  In the first
 part of its transit,  it
 reposes upon the tri-
 ceps   muscle,   and
 courses along the in-
 ner border of the co-
 raco-brachialis ;  but
 from  the  point   at
 which that muscle is
 inserted into the hu-
 merus tf\ thp hpnrl  nf p°»<«rior Circumflex, c, Bra-
 merUS, TO me  UeilU Ol cbill  d Profundus Superior.
 the fore-arm,  it re- '^l^mi'i,KJ[\^n^ A^"*K°-
 POSeS UPOn the  bra- Ex'remity'of Radi'u
 r, . ,.   . .         j P«l Luraoient.  ft,
 chialis  internus,  and Palmar .vrcu.  ivii
Anterior Circumflex.
 h, Lower
i.  •', Car.
Superficial
follows the inner border of the biceps.  In
the upper three-fourths of the arm, it  is
covered by the integuments and brachial
fascia; but a little above the elbow, it per-
forates that fascia, and descends  into the
bend  of the arm beneath the strong apo-
neurotic expansion which is detached from
the tendon of the biceps towards the ulnar
side of the fore-arm.  Having passed be-
neath this expansion, it sinks deep in the
middle of the  triangular space of the bend
of the arm formed by the pronator teres
and supinator longus, and about a finger's
breadth below the joint, divides into the
radial and ulnar arteries. (Fig. 13. 6.) The
artery is  generally accompanied by two
corresponding veins, between  which  it
is placed,  and  several  small transverse
branches frequently pass across it in front,
from  the  one vein to the other.  The ba-
silic vein also runs parallel with  it and is
more superficial. In the upper part of the
arm, the median nerve  courses  along its
outer side,  between it and the coraco-bra-
chialis  muscle,—sometimes immediately
in front; but lower down, the nerve crosses
obliquely in front of the artery, and gets
on the ulnar side of it.  High up, the ul-
nar, radial, and  internal cutaneous nerves,
are likewise  placed upon its  inner side,
and are in such intimate relationship with
it,  as to render  it more difficult to isolate
the artery there, than lower down, where
they  recede  from  the vessel to advance
towards the posterior and internal part  of
the arm.
   In its course  down the arm, the brachial
artery supplies  numerous  branches, most
of which are  of small size, and only a few
of them have had special appellations ap-
plied to them.   Those  which are  small,
and not distinguished by particular names,
are merely distributed to the muscles and
integuments  situated in the vicinity of the
brachial artery, and may be divided into
externa], anterior,  internal, and posterior.
    The external branches are neither large
 nor numerous.   In the  upper part of the
 arm, there is generally one or  more dis-
 tributed to the coraco-brachialis, and lower
 down, a few  others, which glide into the
 space between the biceps and  brachialis
 internus, and distribute their ramusculi to
 both those  muscles.
    The  anterior branches  are  also small
 and irregular in their origin.  Sometimes,
 however, there are three or four of con-
 siderable  size  distributed to the biceps
 muscle, and  those which do not have this
 destination,  are  expended  upon  the  in-
 teguments.
    The  internal, with  the exception  of 
ARTERIES. (Special Anat.)
347
three presently  to be  described, are of
small size, though sometimes numerous.
Some of them, which come off high up,
are distributed to the parts about the ax-
illa,—especially to  the pectoraiis major
and deltoid.  Others take their course to-
wards the adjacent portion of the triceps,
in which they  ramify  extensively  from
the one extremity of it to the other.
  The posterior branches, which are  very
small, are  mostly expended upon the bra-
chialis internus, but  some of them reach
the biceps, deltoid and triceps muscle.
  The branches of the  brachial artery to
which particular names  have  been ap-
plied, are three in number:
  a.  Ramus profundus superior,  s. col-
lateralis magnus.   (Fig. 12.  d.)   This
branch, which is the largest given  off by
the brachial, occasionally takes  its  origin
from the external circumflex or the  sub-
scapular.  When it  arises directly from
the brachial,  it comes  off a little below
the attachment of the latissimus dorsi, and
taking its course backwards, twines round
the posterior face of the humerus, between
the bone and the long head of the triceps,
accompanied in its transit by the musculo-
spiral nerve.   Having  reached  the outer
part of the arm, it glides into  the space
between the  triceps and brachialis inter-
nus, and becomes superficial.  It then de-
scends along the outer part of the  arm,
in the groove or depression between these
muscles, towards the external condyle of
the humerus; and a little above the el-
bow, divides  into an anterior and a poste-
rior branch.  The first descends between
the brachialis internus and  the integu-
ments, and after distributing numerous ra-
musculi to those parts, and to the supina-
tors and the anterior  part of the elbow
joint, anastomoses with the radial recur-
rent.   The posterior branch descends be-
tween  the triceps  and long  supinator,
sending branches to both those muscles,
and then glides behind the external  con-
dyle of the humerus, where it distributes
ramifications  to the  anconseus,  and forms
an  extensive anastomosis with  the inter-
osseous recurrent  It also ramifies exten-
sively upon the posterior face of the hu-
merus, above the articulation; and one of
these branches, larger than the  others,
takes its  course across the posterior face
of the bone, immediately above the  fossa
which receives the olecranon, and by an-
astomosing with the internal  collateral,
forms the arcus dorsalis articularis.
  The external collateral ramus,  in the
first part of its course, gives off several
ramifications to the triceps muscle, which
are distributed extensively in the course
of that muscle; and near the middle of
the arm, it gives off the ramulus nutritius
humeri, which enters the bone, and is ex-
pended upon  the medullary  membrane.
This branch sometimes comes off directly
from the brachial.
  b. Ramus profundus, s. collateralis in-
ferior. (Fig. 12. e.)  The inferior colla-
teral, or profound branch of the  brachial
artery, is much smaller than the  superior.
It arises ordinarily about the upper part
of the inferior  third of the arm, and pro-
ceeds directly inwards, along the  anterior
face of the brachialis internus, and behind
the median  nerve.  In this course, it di-
vides  into two series of branches.   The
anterior run directly downwards  in front
of the internal condyle  of the humerus,
and between the brachialis  internus and
pronator teres,  sending numerous ramus-
culi to these muscles and to the  articula-
tion, and anastomosing with the anterior
ulnar recurrent.  The posterior perforate
the intermuscular ligament which sepa-
rates the brachialis internus from the tri-
ceps,  and thus arrive at the posterior in-
ternal part of the arm. They then send nu-
merous ramifications to the triceps, and
the posterior face of the humerus.   One
of the latter unites with  a branch from
the external collateral to form the arcus
dorsalis articularis, as previously explain-
ed.  The principal branch,  however, de-
scends in the space between the internal
condyle  and the olecranon, in  company
with the ulnar nerve, and after ramifying
extensively upon the parts in the vicinity
of the internal condyle,  anastomoses with
the posterior ulnar recurrent.
  c. Ramus anastomoticus magnus (Fig.
12. /) is rather a  small branch, which
arises from the posterior internal part of
the brachial a little above the  internal
condyle.  It advances directly  inwards,
between the brachialis  internus  and the
median nerve, and having given off some
small branches to the muscle, perforates
the aponeurosis which separates the bra-
chialis internus from the triceps.  It then
usually divides into two branches.   One
of these is  expended upon the triceps,—
the other descends between that muscle
and the aponeurotic band already referred
to, and anastomoses in the vicinity of the
internal condyle with the  inferior colla-
teral, and the ulnar recurrent.
   After giving off these branches, the bra-
chial artery glides beneath the  aponeu-
rotic expansion sent by the tendon of the
biceps to the ulnar side of the  fore-arm,
sinks deep in the triangular space situated 
348
ARTERIES.  (Special Anat.)
Pig. 13.
at the fold  of the  elbow,  and on a level
with the coracoid process of the ulna, di-
vides into the radial  and ulnar arteries
(Fig. 13. 6.), which separate  from each
other at an acute angle.  Not unfrequently
this  division takes place higher up, and
sometimes even in the axilla.
  d. Ramus radialis.  (Fig. 12. g.. Fig.
13. c.)  The radial artery is  somewhat
smaller and more su-
perficial than the ul-
nar* and may be con-
sidered the continua-
tion of the brachial,
since it preserves the
direction of that ves-
sel.  It descends upon
the radial side of the
fore-arm,  in the di-
rection of a line ex-
tending from the cen-
tral   point  between
the two  condyles  of
the  humerus  to  the
articulation  of  the
thumb with the tra-
pezium,  until  it ar-
rives on  a level with
the radio-carpal arti-
culation,  where   it
twines   round   the
outer surface  of the
lower extremity  of
the  radius, beneath
the   extensor  mus-
cles  of  the thumb,
to reach the posterior
part of the wrist   It
then takes its course
between the first and
second   metacarpal
bones,  and  finally
plunges  directly for-
wards in the  notch
between these bones,
to enter the palm  of Braiwat
trip  hnnrl  whprp  it current Radial,  e, Superficial
me  nana, wnere  n Vo)ar  f< Deep.,eated 'palmar.
runs acrOSS the me- f> Union of Radial and Ulnar.
       . ,        ,.     A, Ulnar,  t, Posterior Recur-
lacarpal bones to form rent. *, Interosseua,  I, Com-
the palmar arch.      mimiclD'- "•• me™"'
   In the upper third of the fore-arm, the
radial artery reposes upon the tendinous
portion of the  short supinator and  some
filaments from the  radial nerve, the latter
being on its outer side, and somewhat re-
moved from it.   In the same region, it is
in relation, on its ulnar side, with the pro-
nator teres, while  on  its radial side, the
long supinator is in contact  and overlaps
it to some extent.   In the middle third of
the fore-arm, it glides  in front  of the ten-
don of the pronator teres, and afterwards,
JTWs
a. Brachial,  b, Division_of
      C Radial,  d.
upon  the  flexor longus pollicis and flexor
sublimis.   In the inferior third,  it  runs
first over the surface of the pronator quad-
ratus, and then reposes in immediate con-
tact with  the  mxlius.  Throughout  the
whole of  this extent,  it has the long su-
pinator muscle on its outer side,—first its
fleshy, and afterwards its tendinous por-
tion.   The radial nerve  also runs parallel
with  it on  the  outer side.  On its  ulnar
side, after passing over the pronator teres,
it has the flexor carpii  radialis muscle and
its  elongated tendon.  It is accompanied
by  two  corresponding  veins, between
which it marches; and in  front it is co-
vered above, by the antibrachial fascia and
the long supinator,—lower down, by the
skin and fascia alone.  The superficial ra-
dial vein, which is situated exterior to the
antibrachial fascia, courses along the fore-
arm, directly in front of the  artery.
,  Between its origin  and the wrist  the
radial  artery distributes a great  number
of small branches to the muscles and other
parts  in its vicinity, viz.: outwards to the
supinators  and radial  extensors; inwards
to the pronator teres and flexor carpi ra-
dialis ; backwards to the  flexor longus pol-
licis,  flexor sublimis and profundus, and
pronator quadrates;  and forwards to  the
integuments.  The  only branches,  how-
ever,  which require a particular descrip-
tion, are the following:
  a. R. recurrens radialis.  (Fig. 13. d.)
The recurrent radial branch  is given off
by the radial artery near its origin.  It in-
clines outwards, and then upwards,  form-
ing a sudden curve, and  runs in the space
between the supinator longus  and brevis,
and the brachialis internus. It gives small
ramusculi to all these muscles, to the com-
mon flexors of the fingers, and the radial
extensors, and to the anterior part of the
elbow joint.  Its terminating branches as-
cend in front  of the external condyle, tc
anastomose with  the  external profound
branch of the brachial artery.
  j3.  R. superficialis vola.   (Fig. 13. e.)
About an  inch above the carpus, where
the radial artery begins to  twine round
the inferior extremity  of the bone, it gives
off the superficial volar branch, which va-
ries much  in  size.   It  is  sometimes so
large as to represent the proper continua-
tion of the radial artery,  and in such cases,
the superficial palmar arch is very large.
In other cases, it is very small, and some-
times scarcely exists.  It descends directly
into the palm of the  hand  on its radial
side, running in its course over the palmar
aponeurosis, yet  tied down by  a slip of it
—then between the  attachment of the 
ARTERIES.  (Special Anat.)
349
 short flexor of the thumb, and terminates
 by uniting with the radial extremity of
 the superficial palmar arch formed by the
 ulnar artery, which it thus serves to com-
 plete.   Small branches are furnished by
 it to the wrist, the muscles of the thumb,
 and the structures within the  palm of the
 hand.
   y.  R.  dorsalis carpi  radialis.   This
 branch arises from  the radial on a level
 with the external border of the tendon of
 the long radial extensor, about  an inch
 above its  attachment.  It runs  directly
 across the dorsum of the carpus, under-
 neath all the  extensor tendons, and anas-
 tomoses with  a similar branch of the ul-
 nar.   From the arch thus formed, numer-
 ous branches are sent upwards to anasto-
 mose with the  interosseous;  others pass
 downwards to supply the integuments and
 interossei muscles,  and anastomose  with
 the perforating ramusculi of the  deep
 palmar arch.
   8.  R.  dorsalis metacarpi  radialis is
 given off immediately beyond  the preced-
 ing, and sometimes arises  in common with
 it, or  the dorsalis pollicis.  Its course is
 obliquely across the base of the  metacar-
 pal bone of the index finger  to the back
 of the hand, and it sends ramusculi to the
 abductor indicis, the  integuments, and the
 interosseii muscles.
   c. R.  dorsales pollicis are two small
 branches which sometimes  arise singly,
 —sometimes  in common  from the radial,
 just before it plunges into the space be-
 tween the  thumb and index finger. They
 proceed directly along the dorsum of the
 thumb, the one following the radial, the
 other   the  ulnar  margin, anastomosing
 freely  in their  progress.
  £. jR. dorsalis indicis is a small irregu-
 lar branch, which sometimes  arises near
 the dorsalis pollicis.   It  takes its course
 along the dorsum of the radial margin of
 the index finger, and supplies  small rami-
 fications to the abductor  indicis  and the
 integuments.
  ■n.  R.  magnus,   s. princeps  pollicis.
 After the  radial artery has taken a turn
 forwards, to plunge into the palm of the
 hand, and while it is passing between the
 flexor brevis pollicis  and abductor indicis,
 it gives  off this branch,  which  proceeds
 directly forwards to a level with  the base
 of the first phalanx of the thumb, and di-
 vides  into two  branches.  One  of these
 follows the radial, the other the ulnar bor-
der of the  thumb, on its palmar aspect to
the tip, both branches being connected by
 frequent  anastomoses.
  >.  R. radialis indicis  arises near the
   vol. ii.        30
 preceding, and  follows the radial border
 of the  index finger, first sending small
 branches  to the abductor indicis and ad-
 ductor pollicis, and anastomoses with the
 ulnaris indicis near the tip  of the finger.
  t.   Palmaris  profundus.  (Fig. 13. /.)
 This is the terminating branch  of the ra-
 dial  artery.   Having reached the palm of
 the hand,  it sweeps across it, towards its
 ulnar margin, between the adductor polli-
 cis, the tendons  of the flexors of the fin-
 gers and  the  lumbricales, and the  meta-
 carpal bones,  thus forming  the  profound
 palmar  arch  which has its  convexity to-
 wards the fingers.   This arch is placed
 near the posterior extremities of  the me-
 tacarpal bones, and  is completed by the
 union of the radial with the ulnar artery,
 near  the  metacarpal bone  of  the  ring-
 finger. (Fig. 13. g.)
  The profound palmar arch gives off nu-
 merous ramifications of small size. These
 are,  1.  Several  which come off  from its
 concavity  and proceed towards the carpus,
 to anastomose there with others furnished
 by the ulnar:  2. Others denominated per-
 forating arteries, three in number,  pass
 directly backwards, between the metacar-
 pal bones, perforating the interosseii mus-
 cles, and  anastomose posteriorly with the
 ramifications of the  r. dorsalis carpi radi-
 alis : 3. Several branches proceed  directly
 forwards from the  convexity of the arch,
 which send ramifications to the interosseii
 muscles, and terminate at the anterior ex-
 tremity of the metacarpal bones, by anas-
 tomosing  with the  digital branches fur-
 nished by the superficial palmar arch.
  e.  Ramus ulnaris. (Fig. 13. h.)  The ul-
 nar  artery,  which  is  larger and deeper
 seated than the radial, descends with a
 gradual curve along the ulnar side of the
 fore-arm, from the coronoid process of the
 ulna to the palm of the hand, where it ter-
 minates by forming the superficial palmar
 arch.  In  the upper third  of the arm,
 where it  is deep-seated,  and covered by
 the pronator teres and superficial flexors,
 it descends obliquely towards the ulnar
side  of the fore-arm, forming at the same
 time a slight curve, the convexity of which
 is directed inwards and backwards.  By
 this means it arrives fairly in front of the
 ulna, and  at  the point of union between
 the  upper and middle  thirds of the fore-
 arm,  becomes superficial,  and descends
 thence  in a  perpendicular direction to-
 wards the pisiform bone.  Arrived at the
 wrist, it glides over the surface of the an-
 terior annular ligament, along the radial
side  of the pisiform bone, covered by the
palmar  aponeurosis.  Here,  however,  it 
350
ARTERIES.  (Special Anat.)
 changes its  course,  and sweeps with a
 gradual curve across the palm of the hand,
 superficial to the flexor tendons, towards
 its radial margin, and  unites with the r.
 superficialis  volte of the radial artery to
 form the superficial palmar arch.
   In the upper third  of the fore-arm,  the
 ulnar  artery is covered by  the  pronator
 teres, flexor carpi radialis, flexor sublimis
 digitorum, and palmaris longus.  In  the
 middle and inferior thirds of the fore-arm,
 it is situated in the space between  the
 flexor carpi ulnaris on the inside, and  the
 flexor  sublimis  digitorum and  palmaris
 longus on the outer;  consequently, while
 it is overlapped for a small distance above
 by the two first of these muscles, where
 they become  tendinous, it is only covered
 by the  integuments  and brachial fascia,
 and in the palm of the hand by the palmar
 aponeurosis.  At its origin, the artery  re-
 poses upon the brachialis internus, and is
 intimately connected with  the  median
 nerve, but is immediately afterwards sepa-
 rated from it by the ulnar origin of the
 pronator teres.  Lower down,  it reposes
 upon the  flexor digitorum profundus, and
 .his it continues  to  do, until it arrives at
 the wrist where it rests upon the annular
 .igament and while  it is arching across
 the palm of the hand, upon the flexor ten-
 dons.  In the whole of its course, it is
 placed between  the  two  accompanying
 veins, but does not come in immediate  re-
 lationship with the ulnar nerve, until it
 arrives at the junction between the supe-
 rior and middle thirds of the  fore-arm;—
 the nerve above that point, in consequence
 of its course behind the internal  condyle,
 being considerably removed from it.  From
 this situation, the nerve courses along the
 ulnar side of  the artery, until it arrives at
 the carpus, but there gets a  little behind
 the vessel.
   The ulnar  artery, like the radial, gives
 off an immense number of small ramifica-
 tions to all the muscles  in its  vicinity, but
most of them  are too minute and unimpor-
tant to deserve  names.  The following
branches only, require a  particular de-
scription.
   a. jR. recurrens ulnaris anterior.  The
anterior ulnar recurrent  is  generally a
small branch.  It arises  in  most  cases
from the  ulnar artery  directly  after  its
separation from the radial, but sometimes
in common with the  posterior recurrent.
It passes inwards between the brachialis
 internus and the pronator teres, sends nu-
 merous ramifications to those muscles and
 the anterior part  of the articulation, and
then branches out extensively upon the
 anterior part  of the  internal  condyle,
 where  it forms  a free anastomosis with
 the inferior profunda and the anastomoti-
 cus magnus.
   0. it*, recurrens ulnaris posterior (Fig.
 13. i.) is much larger than the preceding,
 and arises nearly an inch lower down.  It
 passes  inwards and  a  little upwards,  in
 front of the flexor digitorum profundus,
 and behind the pronator teres, flexor carpi
 radialis, palmaris longus, and flexor digito-
 rum sublimis.  Taking its course towards
 the inner condyle of the humerus, it di-
 vides into an anterior and posterior branch.
 The first ramifies extensively upon the
 anterior face of the condyle;—the second
 twines  round the upper part of the ulna,
 in the space between the two attachments
 of the flexor carpi ulnaris, and thus reaches
 the posterior face of the condyle,  where
 it passes in the  depression between that
 body and the olecranon, in company with
 the ulnar nerve, and anastomoses with the
 anastomoticus magnus  and inferior pro-
 funda.
   y.  R. interosseus.  (Fig. 13. k.)  The
 interosseus is the third and largest branch
 of  the   ulnar  artery.   It  arises from
 the posterior part of that vessel, a little
 below the level of the coronoid process of
 the ulna, whence it  proceeds  backwards
 and a little outwards, to  gain the  upper
 part of the interosseous space between the
 ulna and radius, and opposite the tubu-
 rosity of the latter bone,  divides into an
 anterior and a posterior branch.
   The  first, denominated r.  interosseus
 anterior, descends in a perpendicular di-
 rection  upon the anterior part of the in-
 terosseous ligament,  between  the  flexor
 longus  pollicis  and flexor digitorum pro-
 fundus,   distributing   numerous  small
 branches in  its  course to the adjacent
 muscles, and having arrived at the upper
 border of the pronator quadrates it sends
 branches into the substance of that mus-
 cle, which afterwards  descend  in front
 of the carpal bones, and anastomose with
 the anterior carpal ramifications of the ra-
 dial artery.  The main  branch of the an-
 terior interosseous artery, however, perfo-
 rates the interosseous ligament on a level
 with the upper  margin of the pronator
 quadrates, and  descends  posteriorly, be-
 tween the radius and ulna, to the wrist,
 where it divides  into numerous ramifica-
 tions, which anastomose extensively with
 those of the posterior interosseous and the
r. carpi radialis.
  The posterior interosseous artery passes
downwards and backwards, through  the
interosseous space between  the  upper 
ARTERIES.
part of the interosseous and oblique liga-
ment.  It thus reaches the posterior part
of the arm, and near the  edge of the an-
coneeus muscle, divides into two branches
of nearly equal magnitude;—the  poste-
rior interosseous recurrent, and the pro-
per posterior interosseous.
  The posterior interosseous recurrent is
reflected directly backwards and upwards;
ascends between the short supinator  and
the anconseus muscles, then between the
latter and the extensor  carpi ulnaris, to
the posterior part of the  external condyle
of the humerus, where it anastomoses with
the radial recurrent and  the profunda su-
perior.  Its branches are distributed  to the
short supinator, the anconaeus, ulnar  ex-
tensor, the triceps, and the structures sur-
rounding the joint.
   The descending branch is more super-
ficially situated than the  anterior interos-
seous,  and does not like it repose upon
the interosseous ligament, but follows the
space between the  common extensor of
the fingers and the extensors of the thumb.
It furnishes numerous  ramifications of
small size to all the muscles on the poste-
rior part of the fore-arm, and  near the
wrist  divides into middle, external, and
internal branches.   The first anastomose
with the branches of the anterior interos-
seal, the external with the r. carpi radi-
alis, and the internal with the r. carpi ul-
naris.
   8. Ramuli  carpi ulnares anteriores et
posteriores are small branches  given off
from the ulnar artery near the styloid pro-
cess of the ulna.  The anterior ramify ex-
tensively upon the front—the posterior
twine round the bone to the dorsum of the
carpus, underneath the flexor and extensor
tendons, and form a free anastomosis with
the similar branches furnished by the ra-
dial artery.
   The ulnar artery  then continues its
course over the carpal ligament (Fig. 12.
i.) along the radial side of the pisiform
bone,  tied down by a slip of the palmar
 aponeurosis, and on a level with the  base
of the metacarpal  bone of the little finger,
 divides  into two terminating branches,—
 the r. communicans, and r. palmaris su-
 perficialis.
   i. R. communicans, s. profundus. (Fig.
 13. I.)   This branch, accompanied by a
 branch  of the ulnar nerve,  plunges pro-
 foundly into the ulnar side of the palm of
 the hand, by passing between the short
 flexor  and the abductor  muscle  of the
 little  finger,  and  inosculates  with  the
 palmaris profundus of the radial artery, to
 complete the deep palmar arch.
(Special Anat.)                      351

    f. R. palmaris superficialis. (Fig. 12.
  h.)  The superficial palmar branch of the
  ulnar  artery turns  outwards, with a gra-
  dual curve, across  the palm  of the hand,
  exterior to the flexor tendons, and hav-
  ing arrived at the middle of  the metacar-
  pal bone of the index finger, meets the
  superficial volar branch  of the radial ar-
  tery, and  the  radialis  indicis,  and thus
  forms  the superficial palmar arch, the con-
  vexity of which  is directed  towards the
  fingers.  This arch  is placed more ob-
  liquely as regards the hand than the deep-
  seated one, and is also situated nearer the
  fingers.
    From its concavity, small branches are
  given  off, which pass upwards to the car-
  pus, the  annular ligament, and the lumbri-
  cales.  They anastomose with the branches
  of the radial and ulnar arteries already
  described.   The  convexity  of the  arch
  gives  origin to four branches of larger
  size, which pass  directly forwards to the
  fingers,  and are denominated
    <*.  Ramusculi digitales.  (Fig. 13. m,
  m, m.)  The first  digital artery courses
  along the ulnar margin of the hand, and
  after  distributing small branches to the
  muscles and integuments surrounding the
  metacarpal bone of the little finger, is ex-
  pended upon the ulnar side of that finger.
  The second follows the  space  between
  the metacarpal bones of the little and ring
  fingers, and near their heads, divides into
  two branches,  one  of which  supplies the
  radial side of the little finger,—the other
  the ulnar side of  the ring  finger.   The
  third courses along the space between the
  middle  and ring fingers, and divides,  to
  send  a  branch to  the radial side of the
  latter, and  the ulnar side of the former.
  The  fourth in like  manner follows the
  space between the metacarpal  bones  of
  the middle  and index fingers, and divides
  anteriorly to supply the radial side of the
  one, and the ulnar side of the other.  The
  radial side of the index finger is supplied
  by the radial artery, as previously  de-
  scribed.
     In  their course  along the sides of the
  fingers, the digital arteries give off nu-
  merous small ramifications to their dorsal
  and palmar faces, which  supply the soft
  parts,  and form  frequent  anastomoses.
  Those which appertain to each finger are
  accompanied by branches of the ulnar and
  median nerves,  and as they approach the
  anterior phalanx, they converge from op-
  posite sides, and inosculate upon the mid
  die of its palmar face, to  form a small
  arch, from the convexity of which an  in-
  finity of delicate ramifications are  given 
352                       ARTERIES. (Special Anat.)
off, which form  a complex  vascular net-
work upon the ball or tip of each finger.
  Varieties of the axillary  and  brachial
arteries, and their principal branches :
  It is not unusual for the thoracic  arte-
ries to arise by a common trunk.  Some-
times one or more of them arise from the
subscapular  artery,  and in rare cases,
where  there is a  high bifurcation of the
arteries of the arm, from  the superior pro-
funda, or even the radial artery.  (Green.)
  The subscapular artery seldom presents
much variety in its origin.  Monro has
nevertheless remarked, that it sometimes
arises from the inferior thyroid. (Outlines
of Anatomy.  III.  103.)  Green  has de-
scribed  an  anomaly somewhat similar.
" From the  subclavian, just as it crossed
the first rib, arose a very large vessel, di-
viding into  all  the thoracic arteries, and
continued on to  the  scapula, to become
subscapular." p. 15.
  The anterior  and posterior circumflex
arteries  sometimes  arise by  a  common
trunk.   Sometimes one  or  both of  them
come from the  superior profunda—some-
times from the subscapular,  and occasion-
ally, when the radial  has  a high origin,
from that vessel.
   Brachial artery.  There  is no part of
the  arterial  system  which presents  so
many anomalies as  the brachial artery.
They are indeed so numerous, that to de-
scribe  them  all in this  place, would re-
quire more space than can be conveniently
allotted to the subject.  These anomalies
consist mainly in the  high origin of the
arteries of the arm, and in  the  existence
of  irregular branches,  denominated  by
Burns, vasa aberrantia.
   In some cases, the brachial artery, in-
stead of dividing  in the  bend of the arm,
divides higher up.  The point at which
this division takes place varies.  Some-
times it occurs a little above the elbow—
sometimes about the middle or in the up-
per  third of the arm,  and occasionally
within the cavity of the axilla.   In some
instances, the  radial  and ulnar arteries,
after separating high in the arm, or in the
axilla, pass for a limited  distance  down
the arm, and again unite. The vasa aber-
rantia consist of branches of variable mag-
nitude which arise  from the brachial or
subscapular arteries, and descend to unite
below with either the  radial, ulnar, or re-
current  arteries,—more frequently with
the former.  Sometimes a large branch
proceeds from the axillary and descends
parallel  with the brachial  artery, to the
internal condyle of the humerus, to anas-
 tomose with the ulnar recurrent  Occa-
sionally a similar branch arises  from tlie
superior  profunda.  This condition  may
also exist with the origin of the profunda
itself from the  subscapular or its circum-
flex branch, or from the posterior circum-
flex. (Tiedemann. Tab. XIII., Barclay.)
  The high bifurcation of the brachial ar-
tery is of so frequent occurrence, that it
was  described by Bidlo as the natural
distribution.  It has  been  estimated by
Green, that the proportion of the irregu-
lar to the regular distribution, is as one to
four, which accords with the observations
of Harrison, who found varieties in the
arteries of the  arm in twenty-one out of
eighty subjects.
  When the high bifurcation takes place,
the radial  is more frequently the branch
given  off  than  the ulnar.   Meckel re-
marks, that  in  twenty-two examples of
high bifurcation in his possession, the ra-
dial  artery was the branch  given off in
fourteen—the ulnar in only eight.   (Ar-
chiv. fitr Physiologie. II. 124.) It should
be remarked, however, that when the ul-
nar  artery does take a  high origin, it
comes off generally higher up  than the
radial does under similar circumstances,
and  is oftener  than that vessel given off
in the axilla. (Ibid.)  Only a few cases
have been  recorded  in which the interos-
seous  artery took  its origin above the
elbow.
  The high  bifurcation  of these arteries
often leads to important anomalies in  their
distribution.
  The radial artery, when it takes its ori-
gin  above the  elbow,  or in the axilla,
generally runs  parallel with the brachial,
covered by the aponeuroses, as  under or-
dinary circumstances,  and  pursues  its
usual  distribution   upon  the  fore-arm.
Sometimes,  however, it takes a super-
ficial course, and runs over the tendinous
slip of the biceps muscle.  We have seen
one  case,  in which the radial artery di-
vided  into two  principal branches at the
bend of the  arm, one of which pursued
the natural distribution, and furnished the
superficialis vote, while  the  other twined
over the prominent surface  of the supina-
tor muscles, to the outer and  posterior
part of the arm, where it was  expended
upon the  integuments and muscles.  A
much more common variety of this anom-
aly, is that  in which the artery gives off
the volar branch some distance  above tlie
wrist, and winds round the outer part of
the radius.   In  such cases, the pulse can-
not  be felt at  the wrist, or is preternatu-
rally small.  In some  cases of high bi-
furcation,  a  transverse branch unites the 
                         ARTERIES. (

radial and ulnar in the vicinity of the bend
of the arm, and occasionally the radial re-
current  and a median artery, which  is
distributed to the palm of  the hand, are
furnished from this branch.   In some in-
stances, there are two of these transverse
branches, some distance from each other;
and I have seen one, in which a union of
this  kind between the radial and ulnar,
or rather between the radial and brachial
artery, took place near the axilla.  When
the  ulnar artery is given  off above the
usual point the radial very often gives
off the interosseous branch;  and occasion-
ally, under similar circumstances,  the
branch which is furnished  by the radial,
corresponding to the interosseous, passes
superficially over the surface of the  pro-
nator teres  to the ulnar side of the fore-
arm, to supply the place of  the ulnar ar-
tery, while the  latter, after it emerges
from beneath that muscle, descends in the
natural  course  of  the  interosseous,  and
supplies  its place.
   The ulnar artery, when it comes off
higher up than usual, is exceedingly  irre-
gular  in its distribution.   Sometimes it
passes profoundly,  as in the  natural ar-
rangement  More frequently, however, it
runs immediately beneath  the fascia  of
the  fore-arm, over the surface of  the pro-
nator teres muscle.  In  some instances,
both the radial and ulnar arteries pursue
this superficial course to the wrist.
   The interosseous artery,  it has  been al-
ready remarked, is generally a branch of
the  radial, when a high bifurcation takes
place.   Green saw two cases in which it
terminated in the radial, where that artery
is about  to turn to the back of the thumb.
   There is frequently a median artery,
corresponding in its distribution to the
vein of the  same  name.   It may  arise
either from the radial, ulnar, interosseous,
or humeral,—rarely from   the last but
often from the  interosseous.   It descends
■ to the palm of the hand, sometimes  anas-
 tomosing with the branches of the super-
 ficial arch, occasionally joining the ulnar
 to form  the arch, and supplying the place
 of the volar  branch; in  some cases sup-
 plying some of the digital branches on the
 radial side of the  hand,—and finally ter-
 minating in the princeps pollicis. (Green.)
   There are many other varieties of these
 vessels,  which  it would require too much
 space to enumerate.   They are, indeed,
 nearly endless, and pursue almost  every
 possible variety of distribution.  The  same
 remark  may be made of the palmar arches,
 and the digital arteries, which  so  often
                   30*
Special Anat.)                       •*»

depart from their normal distribution, that
it would be vain to attempt to describe all
their varieties.
   The varieties in the origin and distri-
bution of the arteries of the arm are ex-
ceedingly important, in relation to surgi-
cal operations, and especially in connexion
with venesection.   It is mainly from this
cause that accidents so often happen in
that  operation,  the anomalous course  of
the vessels rendering them very liable to
be opened by the  lancet.
                 Fig. 14
 o, Thoracic Aorta,  c, Bronchial Arteries,  d, Intercostals. e,
(Esophageal.
  The thoracic aorta (aorta thoracica, s.
descendens) (Fig. 14. b.) is that portion
of the vessel comprised between the  ter-
mination of the arch and the diaphragm.
It consequently extends from  about the
level of the fourth dorsal vertebra, to the
twelfth, where it passes through the open-
ing  formed by the interlacement of the
pillars of  the diaphragm, and descends
into the abdomen.  In  the whole of this
course,  it occupies the posterior mediasti-
num, and is placed upon the left side and
in front of the bodies of the vertebra, in-
clining gradually towards the median line
as it descends.  Above, the  root of the
left lung is in front,—and lower down, the
pericardium.  On the left, it is in contact
with the  pleura  of  that  side;—on  the
right it is in relation with the thoracic
duct the vena azygos, and the oesophagus,
—the latter, before it perforates the  dia-
phragm, ranging in front of the artery to
reach its left side.   It is likewise accom-
panied by the pneumogastric nerves,  and
is only separated  from  the vertebra? by
the intercostal veins of the left side.
   All the  branches furnished by the tho-
racic aorta are small,  and may be divided 
354
ARTERIES.  (Special Ana'.)
into  anterior and lateral;—the  first' sup-
plying the parts within the  mediastinum,
—the second, the intercostal spaces.
  a,  Arteria bronchioles inferiores. (Fig.
14. c.)  The bronchial arteries are small
and irregular, both as regards number and
origin.  There are generally from two to
four, which arise separately from the  aor-
ta, about an inch below the termination
of the arch; but sometimes there are only
two, which come off by a common trunk,
the latter dividing into a right and a left
branch.  Not unfrequently the right bron-
chial artery  is a branch of the superior
intercostal, or of the internal mammary.
The left takes its course outwards, along
the  posterior face  of the  corresponding
bronchus;—the right proceeds in an op-
posite direction behind the  oesophagus, to
the  posterior face of the right  bronchus,
—and both pursue  these  tubes to their
termination in  the substance of the lungs,
dividing, as they divide, into numerous
ramifications, which  twine  upon the air-
tubes,  supplying  their structures,  and
sending, besides,  minute ramusculi  into
the parenchyma of the lungs, and  to the
pulmonary arteries and veins.   They an-
astomose freely with the other vessels of
the  lungs.   Near their origin,  the bron-
chial arteries distribute small branches to
the  oesophagus, aorta, pericardium,  and
bronchial glands.
   Besides these, the bronchi receive other
branches of small size, either from  the
subclavian artery or the arch of the aorta,
which are denominated Arteria bronchi-
ales superiores.
   b.  Arteria  cesophagea.  (Fig. 14. e.)
These  are  small  branches which arise
from the anterior part of the aorta at va-
riable distances below the origin  of the
bronchial arteries.  They vary in number,
from two to six or seven,  and generally
proceed forwards and a little downwards,
to distribute their ramifications chiefly to
the  walls of the oesophagus;  but in part
also to the posterior mediastinum, and the
coats of the aorta.  Ramifications are sent
upwards to anastomose with the branches
of the bronchial and inferior thyroid arte-
ries, while others proceed downwards, and
anastomose freely with the phrenic  and
coronary artery of the stomach.
   c. Arteria mediastini posteriores.  The
posterior mediastinal arteries consist of a
number of very minute branches, derived
in part from the anterior face of the aorta,
but likewise from the oesophageal branches,
and the intercostals.  They plunge  into
the  posterior mediastinum, sending also
some  ramifications to the coats of the
aorta and the oesophagus, and form a very
delicate vascular net-work, by their anas-
tomoses with the oesophageal, thymic, and
phrenic arteries.           *
  d. Arteria intercoslales inferiores. (Fig.
14. d, d, d, d, d, d.) The number of the in-
ferior intercostal arteries varies,  according
as one, two, or three of the upper intercos-
tal spaces are supplied from the superior
intercostal, which is derived from the sub-
clavian.  Generally,  there  are  eight or
nine on  each side, all of which proceed
from the posterior lateral part of the aorta,
the upper ones at an acute,—the lower at
an obtuse angle. Those of the  right side
are longer than  those of the left, because
of the inclination of the aorta in the latter
direction.  The upper intercostals, more-
over, abcend  more than the lower, in con-
sequence of  their origin  forming a more
acute angle with the aorta.  On the right
side, each artery takes its course towards
the intercostal space it is destined to sup-
ply,  passing  first in front of the vertebra,
and  behind the oesophagus, vena azygos,
and thoracic  duct,—then behind the sym-
pathetic nerve, and between the  pleura
and  the  posterior extremity of the exter-
nal intercostal muscle.   On the left, the
artery passes at once  behind the sympa-
thetic  nerve, and between the pleura and
intercostal muscle.  In other respects, the
distribution is the same on both  sides. Ar-
rived near the costo-vertebral articulation,
each intercostal artery divides  into a pos-
terior and an anterior branch.
   a. Ramus dorsalis.   This branch is re-
flected backwards in  the space between
the corresponding transverse processes of
the vertebra, and after sending small ra-
muli to those bones,  and  one  or  more
which penetrate the  intervertebral  fora-
men to be  expended upon-the membranes
of the  spinal chord, it plunges into the
mass of muscle placed in the  groove by
the side of the  spinous processes, and an-
astomoses above and below with the rami-
fications of the intercostal arteries which
are next to it in those directions.
   £.  Ramus anterior is the proper con-
tinuation of the intercostal artery, and is
larger than  the posterior branch.  It ad-
vances in the  space  between the ribs
which it is  destined to supply, placed at
first between the pleura and the external
intercostal muscle,—then between the two
muscles themselves. Pursuing this course
for a short distance, it divides into an in-
ferior and a superior branch.
   The first  which is smaller  than the
other,  inclines downwards  towards the
upper margin of the adjacent rib,  along 
ARTERIES.
which it runs for some distance, and finally
advances in front of it, supplying ramifi-
cations to the periosteum, and the super-
ficial parts  in  the vicinity.
  The superior branch is much larger.  It
follows the groove which occupies the in-
ferior margin  of the rib, between its cor-
responding vein and nerve, until it reaches
the anterior third of its transit, when it
deserts the groove to follow the middle of
the intercostal space.  It gives branches
to the intercostal muscles, the periosteum,
pleura, and superficial muscles in the vi-
cinity, and finally terminates by anasto-
mosing with the next intercostals above
and below.   Those which  belong to the
true ribs, also anastomose anteriorly with
the branches  of the anterior intercostals
of the internal mammary, while the ante-
rior branches  of those which appertain to
the false ribs, reach the abdominal mus-
cles,  and anastomose  with the  internal
mammary,  the epigastric,  phrenic, and
circumflexus ilii.
  The  upper  aortal  intercostal, anasto-
moses above with the last intercostal fur-
nished by the  subclavian.  The last one is
concealed by the pillar of the diaphragm,
to which it distributes branches: it then
expends its ramifications upon the broad
muscles of the abdomen, and sends seve-
ral downwards between them, to anasto-
mose with  the lumbar and circumflexus
ilii arteries.
   The abdominal  portion  of the aorta
(pars abdominalis  aorta)   (Fig. 17. *.)
reaches from the  point at which that ves-
sel emerges from between  the pillars of
the diaphragm, to the lower margin of the
fourth lumbar vertebra,  where  it termi-
nates by dividing into the right  and  left
primitive iliac arteries  (Fig. 17. h.), and
the middle sacral (Fig. 17. e.).   While
the artery  is  gliding through  the aortic
foramen  of the diaphragm,  it is tied down
firmly by the  interlacement of the fibres
of the  crura  of that muscle.   On  the
twelfth dorsal vertebra, it reposes nearly
on the median line of the spinal column:
below that point it  inclines a little to the
left, presenting a slight concavity to the
opposite  side, but again reaches the median
line where  it divides.   It is also convex
forwards, to correspond  with the curva-
ture of this portion  of the spine, against
which it may be  compressed in lean sub-
jects, in  cases of uterine or other forms of
hemorrhage taking place from its branches,
by directing the force backwards against
the bodies  of  the vertebra.
  On first entering the abdomen, the aorta
has in front the solar plexus of nerves,
(Special Anat.)                      <&>

  the stomach, and omentum minus: lower
  down, on a level with the second lumbar
  vertebra,  it is crossed by the splenic vein
  and the pancreas,  and immediately below
  the last organ, by the duodenum and left
  emulgent vein.  From this point to  its
  termination, it is  placed  behind the root
  of the mesentery.  In its  whole course
  through  the abdomen, the nervous fila-
  ments twine around its surface, and invest
  it in an intricate plexus.  On  the  right
  side, the aorta is in relation with the vena
  cava throughout, and in the upper portion
  of the abdomen, with  the vena azygos and
  thoracic duct, which pass between it and
  the right pillar of the diaphragm: on the
  left,  it is accompanied by the continuous
  trunk of the sympathetic nerve.
    The arteries furnished by the abdominal
  portion of the aorta, may be divided into
  anterior and lateral.
    The anterior branches are,
    O.  Arteria phrenica, s. diaphragmati-
  ca inferiores. (Fig. 17.  a.)  The  phrenic
  arteries are very irregular  as to their ori-
  gin.  They are generally the first branches
  given off by the aorta after it enters the
  abdomen, and either arise separately from
  that vessel,  or by a common trunk which
  immediately divides  into the  right and
  left phrenic arteries. They are, never-
  theless, often branches of the coeliac axis,
  and in some cases  one or both of them take
  their origin from the superior mesenteric,
  emulgent or one  of the capsular arteries.
    a. Arteria phrenica dextra proceeds up-
  wards and  outwards, over the margin of
  the corresponding pillar  of the diaphragm,
  sending in  its  course small  branches  to
  that muscle, and to  the supra-renal cap-
  sule (r. supra-renales medii).  It glides
  behind the vena cava, and having reached
  the lower border of the  cordiform tendon
  of the diaphragm, divides into an anterior
  alid a posterior branch.
    The anterior branch,  which is the con-
  tinuation of the artery, sends a small ra-
  mulus in front of the oesophagus, to anas-
  tomose with a similar one from  the oppo-
  site side.  It then glides between the dia-
  phragm and the adherent  portion of the
  liver, sends small branches into that or-
  gan, and continues its course upwards and
  forwards along the right side  of the vena
  cava, in  the vicinity of which it sends
  several small ramifications to that vein, as
  well as others which pass upwards to the
  pericardium. It finally  distributes some
  of its ramifications to the  costal  portion
  of the diaphragm, some of which  wind
  round the circumference of the  cordiform
  tendon, to. anastomose with the anterior 
356
ARTERIES.  (Special Anat.)
branch of the left phrenic; others range
in an opposite direction, and anastomose
with the posterior branch; while there are
some which form an extensive anastomo-
sis with the branches of the internal mam-
mary, intercostal,  and epigastric arteries.
  The posterior,  or  external branch, is
much smaller. It takes a transverse course
above the  liver, towards the  right costal
portion of the diaphragm, upon the fleshy
digitations of which its  ramifications are
chiefly expended.  It also distributes some
small branches to the supra-renal capsules
(r. supra-renales superiores), and anasto-
moses  with  the  epigastric,  intercostal,
lumbar, and circumflexus ilii arteries
  j3. Arteria phrenica sinistra winds over
the left pillar of the diaphragm, and pur-
sues nearly the same  order  in  its distri-
bution  as the right.   Advancing upwards
and  forwards  in an oblique direction, it
detaches  a  considerable branch to the
oesophagus, which ascends with it through
the diaphragm, and anastomoses with the
oesophageal branches.  The artery  then
divides, like the right phrenic, into an an-
terior and  an external branch, which are
distributed precisely in the same manner
as the artery of the right side, except that
some of the ramifications of the external
branch are expended upon the spleen.
                Fig. 15.
 a, Cceliac.  b, Superior Coronary, c, Splenic  d, Right Gastro-
epiploic,  e, Hepatic  /, Pancreatico-duodinal.   g, Left Gastro-
epiploic.
 1, Liver.  2, Gall-bladder. 3, Stomach.  4, Spleen.  5, Duode-
num. 6, Pancreas.
  P.  Arteria s. axis cozliaca. (Fig. 15. a.
Fig. 17.  b.)   The coeliac  artery  arises
from the anterior face of the aorta where
it emerges between the pillars of the dia-
phragm, and about the  level of the point
of junction between the  last dorsal and
the first lumbar vertebras. It projects for-
wards, with  a slight inclination  down-
wards, to the extent of from a half  to
three-fourths  of an inch, when  it divides
into three  branches:—the superior coro-
nary artery of the stomach, the hepatic,
and the splenic, which represent a tripod
arrangement.   Sometimes,  also,  one or
both phrenics are branches of this vessel,
and  occasionally the superior mesenteric
likewise arises in common with it.
  The cceliac  artery is situated between
the lesser  curvature  of the  stomach and
the diaphragm.  In front, it  has the  gas-
tro-hepatic omentum and the left lobe of
the liver; on  the  right side, and  a little
upwards,  the  lobulus spegelii; on  both
sides, the  semilunar ganglia and  supra-
renal capsules; and below,  the superior
mesenteric artery, the pancreas, and vena
portarum.  The  solar  plexus of nerves
twines  its  filaments  around  it  which
are  likewise  distributed  upon  its three
branches.
  a. Ramus coronarius ventriculi, s. gas-
tricus superior. (Fig. 15. b.)  The supe-
rior coronary artery of the stomach is the
smallest of the three branches furnished
by the coeliac, except  when it furnishes
the left hepatic ramulus, when it is often
as large as  the hepatic branch  proper.
From the coeliac axis, it proceeds upwards
and forwards, inclining a little to the left,
to reach the lesser curvature of the sto-
mach on the right side  of the cardiac ori-
fice.  It then passes between the two lay-
ers of the gastro-hepatic omentum, and
divides  into two branches, which  may be
denominated oesophageal and gastric.
  The branches which are  destined for
the oesophagus pursue a different direction
according  to  their  situation.   Some of
them take a perpendicular course, and as-
cend with that tube  upwards into the
thorax, and besides sending numerous ra-
musculi to  its walls, inosculate freely with
the superior oesophageal branches.  Others
wind around the posterior circumference
of the  cardia, and send numerous ramifi-
cations downwards upon  the greater ex-
tremity of the stomach, which anastomose
with the branches  of the splenic artery.
  The gastric branch follows the lesser
curvature of  the  stomach,  between the
two layers  of the gastro-hepatic omentum,
to the pylorus, where it terminates by an-
astomosing with the pyloric branch of the
hepatic artery.  In its course, it sends
small ramifications to the lesser omentum,
but is chiefly expended by a  series of an-
terior and  posterior branches, which de-
scend upon the corresponding faces of the
stomach, and  anastomose freely with the
branches  of  the  gastro-epiploic artery,
which follows the greater curvature of
the organ.
  b. Ramus hepaticus. (Fig. 15. e.) This,
in the adult is the second in size of the
branches of the coeliac;  but in the foetus 
                          ARTERIES.

 it  is even* larger  than the  splenic.   It
 ranges at first forwards, upwards, and to-
 wards the right side, between the portal
 vein and hepatic duct, behind the lesser
 lobe of the liver, and towards the pylorus.
 Arrived  at this point  it ascends slightly,
 to reach the transverse fissure of the liver;
 but before arriving at that organ it divides
 into the  right and left hepatic branches,
 which, surrounded by the capsule of Glis-
 son, plunge into its corresponding lobes,
 and expend themselves upon the intimate
 texture  of the gland.
    Before it reaches the liver, the hepatic
 artery furnishes the following branches:
   o. R. pyloricus, s. coronarius superior
 ventriculi dexter usually arises from the
 hepatic a little to the right of the pylorus.
 It  runs along the upper or concave curva-
 ture of the stomach, from right to left, and
 terminates in one or more branches which
 anastomose with the descending ramulus
 of  the superior left coronary artery of the
 stomach.  It also distributes ramifications
 to the pylorus, the  anterior and posterior
 faces of the adjacent  portion of the sto-
 mach, and to the pancreas. Some of these
 ramifications anastomose  with the r. gas-
 tro-epiploica dextra.
   3. R.  gastro-duodenalis, s.  r. gastricus
 inferior dexter.  This branch generally
 proceeds from the inferior part of the he-
 patic, and descends behind the pylorus to
 the vicinity of the right extremity of the
 greater curvature of the stomach, and the
 posterior part of the second section of the
 duodenum. In this course, it gives several
 small branches  to  the pylorus, the upper
 part of the duodenum, and the adjacent
 portion of the pancreas.  It then divides
 into two branches,  denominated pancrea-
 tico-duodenalis,  and gastro-epiploica dex-
 tra.
  The pancreatico-duodenalis (Fig. 15. f.)
 is a small branch, which descends between
 the vertical portion of the duodenum and
 the head of the pancreas, sending ramifica-
 tions to both these organs, and especially
 one branch, larger than the rest, which
 follows the posterior part of the pancreas
 towards  its splenic extremity.
  The gastro-epiploica dextra (Fig. 15.
 d.)  is much larger than the preceding.  It
 sweeps along the greater curvature of the
 stomach  from  right to left, between the
 two laminae of the peritoneum which form
 the  omentum  majus, and about midway
 between  the pylorus and  spleen,  termi-
nates by  anastomosing with the  left gas-
tro-epiploic branch  of the  splenic artery.
It distributes numerous branches  down-
 wards to  the omentum  and the transverse
Special Anat.)                      357

 arch of the colon,  and others upwards,
 which  ramify extensively upon both faces
 of the  stomach, and anastomose with the
 branches of the  pyloric and superior co-
 ronary of the stomach.
   After the hepatic artery has reached
 the transverse fissure of the liver, and di-
 vided into  a right  and a left branch, it
 gives off the ramulus  cysticus, to supply
 the coats of the gall-bladder.
   y. R. cysticus.   This  small ramulus
 arises from the  right hepatic artery, and
 turning upon the neck of the gall-bladder,
 divides into two branches.   One of them
 ramifies extensively upon  the  lower face
 of the  vesicle, between the mucous and
 peritoneal coats; the other branches out
 between the liver  and the gall-bladder,
 distributing ramifications to both.
   c. Ramus splenicus. (Fig. 15. c.) This,
 in the  adult, is the largest of the three
 branches given off by the coeliac.   It
 ranges from right to left, below and be-
 hind the stomach,  and along the upper
 margin  of the pancreas, in the fissure or
 groove of which it is lodged.  Its course
 is often very tortuous, and before reaching
 the fissure  of the spleen, it furnishes the
 following branches:
   a.  R. pancreatici, irregular in number
 and size, which plunge  into the substance
 of the  pancreas,  through which they ra-
 mify minutely, and  anastomose with the
 branches sent to this gland by the pan-
 creatico-duodenalis.   There is sometimes
 one larger than the  rest sent to the left
 extremity of the gland, which has received
 the  appellation of  r. magnus pancrea-
 ticus.
  3. R. gastro-epiploicus sinister, s. gastri-
 cus inferior. (Fig. 15. g.) This branch is of
 considerable size.  It first ascends slightly
 towards the greater  cul-de-sac of the sto-
 mach,  by  which  it is concealed,—then
 inclines forwards and downwards,  and
ranges from left to right, along the greater
curvature of the stomach, and between
the layers of the great omentum.  It dis-
tributes several small branches to the pan-
creas ; but its chief ramifications are those
which  it sends  upwards to the anterior
and posterior faces of the stomach, which
anastomose  with the superior  coronary
branch; and others which descend in the
left  half of the  great omentum, and to
the corresponding portion of the arch of
the  colon.  About midway of  the  great
curvature of the stomach, the gastro-epi-
ploicus  sinister terminates  by anastomos-
ing with the right gastroepiploic branch.
  y. R. splenici  are  the proper terminal
branches of the  splenic artery.  Before 
358
ARTERIES.  (Special Anat.)
the vessel reaches the fissure or hilus of
the organ, it generally divides into two
principal branches, which proceed between
the two layers of the gastro-splenic omen-
tum towards the fissure,  and  subdivide
into a variable number of smaller branches.
These latter are disposed  in a  series cor-
responding to the long axis of the organ
which they penetrate, and then ramify
and anastomose in a very intricate man-
ner through its substance.
  8.  R.  breves.  Vasa brevia.  These
branches vary  in number, from three to
six or seven.   They proceed either from
the trunk  of the splenic artery, or from
some of its branches, before they plunge
into the substance of the organ. Inclining
upwards and from left to right, they reach
the  greater cul-de-sac of the stomach,
upon both faces of which they ramify, and
approaching the  cardia, anastomose with
the oesophageal branches of the superior
left coronary artery of the stomach.
Fig. 16.
 a, Superior Mesenteric, b, Right Upper Colic c, Right Middle
Colic  d, Right Lower Colic, e, Ileo-colic /, Rami Meeentericae.
  Q. Arteria mesenterica superior. (Fig.
16. a.) The superior mesenteric artery near-
ly equals the coeliac in size, and generally
arises from  the front of the aorta, about
three or four lines below the origin of the
vessel just  mentioned.  It extends  from
this  point with a gentle curve, the con-
vexity of which is to the left and forwards,
to the right iliac fossa, where  it termi-
nates.  The pancreas is placed above and
in front of its origin, but it descends be-
fore  the third section of the duodenum,
and  behind the transverse arch of  the co-
lon, to the upper extremity of the mesen-
tery, where, engaging itself between the
laminte of that duplicature of the perito-
neum, it pursues its course, inclining more
and more towards  the intestine as it de-
scends.
  Near its origin, the superior mesenteric
artery furnishes  several  small ramifica-
tions  to the  pancreas, which anastomose
with  the branches sent to that gland by
the hepatic and splenic arteries.  The fol-
lowing, however, are  its most important
branches:
  Branches  which arise from  the con-
cavity of the superior mesenteric artery:
  a. Ramus colicus superior dexter. (Fig.
16. b.)   This branch is given off where
the superior mesenteric passes the great
transverse mesocolon.  It glides in the
space between the layers of that duplica-
ture,  towards the middle of the transverse
arch of the colon, but divides at some dis-
tance from  the  intestine into a left and a
right  branch,  which recede  from  each
other at a very obtuse angle.
  a.  R. anastomoticus sinister, arising in
this manner, sweeps along the  direction
of the left portion of the arch of the  co-
lon, and having  reached the commence-
ment of the descending portion of that in-
testine,  anastomoses  with the ascending
branch of the  superior left  colic branch
of the inferior mesenteric artery.
   8.   R. anastomoticus  dexter.   This
branch arches  round in the same way to-
wards the right side, and terminates by a
similar  anastomosis  with the ascending
branch of the right middle colic.  Both it
and the preceding supply the portions of
the colon and mesocolon to which they
are distributed.
   b.  Ramus colicus medius dexter. (Fig.
 16. c.)  The general arrangement of  this
 branch is very similar  to that of the pre-
 ceding.  It  generally  arises lower down,
 but occasionally both  branches  come off
 by a common trunk,  as represented in
 Fig. 16. In either  case, it advances ob-
 liquely downwards, forwards, and towards
 the right side, and runs between the lay-
 ers of the mesocolon to the vicinity of the
 middle of  the  ascending colon, when  it
 divides into an ascending and a descend-
 ing anastomosing branch.
   a.  R. anastomoticus  superior  sweeps
 round in the direction of the concave face
 of the  colon, where  it forms  the  com-
 mencement of the arch, and anastomoses
 with the right anastomosing branch of the
 vessel last described.
    3.   R.  anastomoticus  inferior  passes
 downwards with a  similar  curve, along 
ARTERIES.  (Special Anat.)
the ascending colon, and forms an anasto-
mosis with the ascending branch  of the
right inferior colic.
  c. Ramus colicus  inferior dexter,  s.
Uio-colicus.  (Fig. 16. d.)  This is a very
large branch, and may be considered  as
the termination of the superior mesenteric
artery.  It arises a little lower down than
the last—sometimes in common with  it
and advances towards  the right side, be-
tween the layers  of the mesocolon, to the
point of union  between the ileon and cae-
cum, in the vicinity  of which  it divides
into the three following branches:
   a.  R.  anastomoticus superior,  which
ascends to anastomose with  the  descend-
ing branch of the right middle colic.
   3-  R.  anastomoticus inferior.    This
branch glides into the fold of the mesen-
tery, and forms an arch, by anastomosing
with the  mesenteric ramifications which
ure distributed to  that structure.
  y. R. ileo-colicus. (Fig. 16. e.)  The ileo-
colic ramulus is intermediate between the
two last and arises from the angle formed
by their division.  It passes directly to the
posterior part of the caecum, where it is
joined by the ileon.   One branch is dis-
tributed  to  the fold  of the peritoneum
which invests  the vermiform appendage,
and supplies that process: another ascends
along the posterior part of the  colon, to
anastomose  with the vessels above; while
a third distributes its ramifications to the
anterior and posterior face of the caecum
and the ileo-caecal valve.
   Branches which arise  from  the con-
vexity of the superior mesenteric artery:
   d.  Rami  mesenterica, s. r.  intestini
tenuis.  (Fig. 16. /)   From the convexity
of the superior mesenteric artery,  fifteen
or twenty branches are given off, destined
to supply the whole  of the  small  intes-
tines, except the upper part of the duode-
num.  They descend from  right to left,
contained within  the fold of the mesen-
tery, towards the respective portions  of
the small intestines which it is their office
to supply. The upper branches are short;
those which are  lower down, somewhat
longer; while  those which  are  the  most
inferior  become  again  shorter.   Each
branch, after passing for some distance
from its origin in the fold of the mesen-
tery, divides into two, which recede from
each other; the one turning upwards to
form an arch by anastomosing with a ra-
mulus sent off  by the next branch above;
the other turning downwards to form  in
the same  manner, a similar arch  below.
From the convexity of these curves, which
is  directed  towards the intestine,  other
359
branches arise, which divide and anasto-
mose  after the  same manner to form a
second series of arches, and by a succes-
sion of divisions and subsequent anasto-
moses, the series of curves are multiplied
to three, four, or five, the ramifications of
which become  progressively smaller, but
at the same time more closely interwoven
with each other. Finally, having reached
the junction  of the mesentery  with the
intestine, a multiplicity of minute ramus-
culi twine around the anterior and poste-
rior faces of the gut between its tunics,
and which by  their anastomoses   form
rings  which  encircle  it:  they  likewise
constitute an extremely fine vascular net-
work  in the  body of the  mucous mem-
brane and its  villous arrangement.
   Nearly the same arrangement is ob-
served in the  final distribution of the
colic arteries.   Generally, however,  their
branches do not form such an extensive
series of arches; but after forming a  com-
plex vascular intertexture  in the folds of
the mesocolon, distribute their minute ra-
mifications upon the circumference of the
large intestines, around which they  anas-
tomose in the manner just described.
   R.  Arteria mesenterica inferior. (Fig
17. /)   The inferior mesenteric artery is
not so large as the superior.  It takes its
origin, like that vessel, from the anterior
part of the aorta, but much lower down;
its origin being generally not more than
an inch,  or an inch  and a half above the
point at which the aorta divides to form
the primitive iliacs.  Descending with an
oblique  inclination  towards the left  iliac
region, it glides first behind the perito-
neum, until it reaches that portion of the
mesocolon which binds down the sigmoid
flexure of the  colon, between the layers
of which it insinuates itself; and having
reached  the brim of the pelvis, descends
between the layers of the mesorectum,
and behind the intestine,  to the vicinity
of the anus.   Like  the  superior mesen-
teric artery, it forms a curve with its con-
vexity directed to the left, but no branches
are given off from its concave side,  as is
the case with  that vessel.  It  sends off
the following branches, to  supply the left
portion of the colon, and the rectum:
   a.   Ramus colicus  superior  sinister.
(Fig. 17. m.)   This, which is the largest
of the branches of this artery, arises to
the left of the bifurcation of the aorta, and
takes its course outwards and a little up-
wards, in front of the left kidney, to the
left mesocolon,  between the laminae of
which  it  divides into an upper and a lower
anastomosing branch. 
360
ARTERIES.  (Special Anat.)
  a. R.  anastomoticus superior inclines
upwards to the arch of the colon, and ter-
minates by anastomosing with the left an-
astomosing branch of the right superior
colic.
  3. R. anastomoticus inferior descends
between the layers of the mesocolon, and
anastomoses in a similar manner with the
ascending  branch  of the  middle colic,
when that vessel exists, or with the  cor-
responding branch of the left inferior colic.
  b. Ramus colicus medius sinister. (Fig.
17. n.)   This is generally a small branch,
                 Fig. 17.
 *, Aorta, a, Phrenic Arteries.  6, Coeliac.  c, Emulgent. d,
Spermatic  t, Middle Sacral.  /, Inferior Mesenteric,  g, Lum-
bar?.  A, Common Iliac, i, External Iliac, ft, Circumflexus Ilii.
I, Epigastric,  m, Superior Left Colic, n, Left Middle Colic. 0,
Inferior Left Colic p, Capsular Artery, q, Inferior Hemorrhoidal.
and is often either wanting, or comes off
from the superior left colic.  It runs down-
wards  and outwards to the  mesocolon of
the sigmoid flexure of the colon, and like
the preceding, divides into  an ascending
and a descending branch.
  a. R. anastomoticus superior ascends,
and anastomoses with the descending or
inferior branch of the superior left colic.
  3. R. anastomoticus inferior  descends,
to anastomose with the superior branch
of the inferior left colic.
  c. Ramus colicus  inferior sinister, s.
sigmoideus.  (Fig. 17. o.)  This branch
advances towards  the sigmoid flexure of
the colon, and like those described above,
divides into an upper and a lower branch.
  o.  JR. anastomoticus superior ascends,
and anastomoses with the lower branch
of the middle colic.
  3.  R- anastomoticus  inferior  inclines
downwards and anastomoses with the n*.
cending  branch  of the  superior hemor-
rhoidal.
  d. Ramus hamorrhoidalis superior, s.
internus. (Fig. 17. q.)  The superior he-
morrhoidal  artery  is  the last  or termi-
nating branch of the inferior mesenteric.
It runs downwards and inwards, engages
itself between the layers of the mesorec-
tum, and descends behind the intestine to
the vicinity of the anus.  It generally di-
vides high  up into two  branches of un-
equal  magnitude, the smaller  of which
sends a ramusculus upwards in the dupli-
cature of the  mesocolon, to anastomose
with the inferior branch of the  lower left
colic.  The larger branch divides about
the middle  of the  sacrum into  two equal
ramifications, one of which descends upon
each  side of the rectum, and after distri-
buting  numerous small  ramifications  to
the  coats  of that  intestine, anastomoses
freely with the middle and inferior hemor-
rhoidal, and the vesical branches.
  The final distribution  of the  branches
of the inferior mesenteric artery to the
intestines, presents precisely the same ar-
rangement as that observed in the branches
of the superior  mesenteric.   As the  pan-
creaticc-duodenalis anastomoses with the
first branch of the superior  mesenteric,
and the  superior right colic branch asso-
ciates that vessel  with  the  inferior  me-
senteric, there is a continuous chain of.
vascular arches extending the entire length
of the alimentary canal, so intimately  con-
nected  by  their extensive  anastomoses,
that whatever affects the circulation of
one portion, must influence  more or less
that of the others.
  S. Arteria capsulares media. (Fig. 17.
p.)  The superior capsular arteries, which
arise from the phrenic, have been already
described.   Those now to be noticed  con-
sist of from one to three small branches,
which proceed from the lateral part of the
aorta,  above the origin  of the  emulgent
arteries,  and  advance directly outwards
across the pillar of the diaphragm, to the
posterior part of the supra-renal capsules,
upon  which they are expended.  They
likewise send small branches to the pillar
of the diaphragm, the lumbar glands, and
sometimes to the upper part of the ureter.
They are small in the adult, but during 
ARTERIES.  (Special Anat.)
361
the period of foetal life their size is very
considerable.
  T. Arteria renales, s. emulgenles. (Fig.
17. c.)  There are usually two emulgent
arteries—one for each kidney; but some-
times the number is increased.  They are
bo large, that it has been  computed that
they circulate one-eighth the whole mass
of blood,  and certainly  their volume is
proportionately greater  than that of any
other artery  destined to supply a gland.
They usually arise from the side of the
aorta, a little below the origin of the supe-
rior mesenteric; but the right is situated
somewhat lower than the  left, in conse-
quence  of the position of the kidney on
that side.  It is also longer, on account of
the aorta being placed on the left of  the
central line of the spine. Their direction
is almost horizontally outwards, but they
are inclined slightly backwards, and while
both are overlapped by their correspond-
ing veins in front, the right glides behind
the vena cava to reach its point of des-
tination.   Having arrived at the notch or
hilus of the kidney,  each emulgent artery
divides into three or more branches, which
recede from  each other,  glide  between
the vein which is in front  and the pelvis
of the kidney and ureter,  which are  be-
hind,  and finally lose themselves  in  the
substance of the gland.   Previously to
reaching the kidney, the emulgent artery
gives off,—
  a. R. capsulares  inferiores, which take
their  course  towards the suprarenal cap-
sules: and
  b. R. adiposa, consisting of several mi-
nute  ramifications which are distributed
to the adipose substance surrounding the
kidney, and sometimes in part  to the pil-
lars of the diaphragm.
  U.  Arteria spermatica.   (Fig. 17. d.)
The spermatic arteries,  two in number,
one for each side, are remarkable for their
great length in proportion to their size,
and for the tortuous arrangement present-
ed by them near their termination. They
arise, at an acute angle, from the anterior
part of the aorta, a little below the emul-
gents, and above the superior mesenteric.
Not unfrequently one of them is sent off
above the level of  the  other; and some-
times one of them  arises from the emul-
gent artery, and not from the aorta. They
pass downwards, and  slightly  outwards,
behind the peritoneum, and in front of the
psoae  muscles,  the  ureters, and  the  iliac
vessels, which they  cross obliquely.  The
right spermatic artery also  passes in front
of tlie vena cava, and both of them distri-
bute small ramifications to the  adipose
substance, lymphatic glands, and ureters;
and when they have reached the brim of
the pelvis, they present a different ar-
rangement in the two sexea
  In the male, accompanied by the corre-
sponding veins  and the spermatic plexus
of nerves,  they  advance towards the in-
ternal  abdominal  ring, where  they are
joined by the vasa deferentia, with which
they pass downwards in the substance of
the spermatic chord, through the inguinal
canal, to reach to the testicle.   They fur-
nish several small branches to  the  chord
and adjacent parts, and in the vicinity of
the testicle,  divide into two  series of
branches, one of which ramifies upon the
epidydimis, while the other plunges into
the substance of the gland, and  supplies
the tunica albuginea.
  In the female,  the  spermatic arteries
do not leave the cavity  of the abdomen,
but descend into the pelvis, approach the
fold of the broad ligaments of the uterus,
becoming there  exceedingly tortuous, and
expend themselves chiefly upon the ova-
ria.  They also send ramifications  to the
Fallopian tubes, the broad and round liga-
ments, and a few of small size accompany
the latter through the inguinal canal, and
ramify in the fat and integuments of the
labia.
  V. Arteria lumbares. (Fig. \l.g-) The
lumbar arteries are formed upon the same
type, and are distributed precisely as the
intercostals.  They are somewhat larger
than those vessels,  but  vary both as re-
gards volume  and  number.  There are
seldom  fewer than four lumbar arteries
for each side, sometimes five,—but in rare
instances there are only three. They arise
from the posterior lateral part of the aor-
ta,  proceed outwards transversely  across
the  bodies of  the  corresponding lumbar
vertebra,  behind  the  pillar of the dia-
phragm and the fasciculi  of the psoas mus-
cles; and having arrived opposite the root
of the transverse  process, divide into an
anterior and a posterior branch.  The latter
is reflected backwards between the  trans-
verse processes: it sends a branch through
the intervertebral foramen into the spinal
canal, which distributes  its ramifications
to the membranes  of the spinal marrow,
and the  cauda equina.   Other branches,
of small size, are also distributed to the
bodies of the vertebra and adjacent parts;
but the termination of the posterior ramu-
lus is upon the sacro-lumbalis,  multifidus
spinas, and other  muscles  which repose
upon the spinal column.   The upper one
voi- II.
31 
362
ARTERIES.  (Special Anat.)
anastomoses with the posterior branch of
the last intercostal; the lower with the
ileo-lumbar.
  The anterior branch of the first lumbar
artery, which is small, follows the inferior
margin of the last rib, sending ramifica-
tions to the attachment of the diaphragm,
and after proceeding some distance, it  in-
clines downwards, and is expended chiefly
on the transverse muscle of the abdomen.
  The second sends some small branches
to the head of the psoas muscle, but is
mostly spent upon the quadratus lumborum.
  The third is  much larger.   It passes
outwards,  in nearly a horizontal direction,
glides  between the  quadratus  lumborum
and the transversalis, to arrive  in the vi-
cinity of the crista of  the ilium, where it
terminates in two orders of branches, one
of which  is distributed to the broad mus-
cles of the abdomen, while the other in-
clines towards the dorsum of the ilium, to
ramify in the glutei muscles, and anasto-
mose with the arteries of that region.
  The fourth is also large.   It passes di-
rectly outwards, between  the psoas  mus-
cle and the quadratus lumborum, and near
the lower  attachment of the latter.  In its
course, it divides into  numerous ramuli,
some  of which are distributed to the ili-
acus internus, while others reach the cris-
ta of the  ilium, in the space between the
broad abdominal muscles.  Some of these
are distributed to the transversalis and the
two oblique muscles, forming at the  same
time a free anastomosis with the circum-
flexus ilii.  The others wind over the crista
of the ilium, and are expended on the glu-
tei muscles.
  Varieties of the branches  which  arise
from  the  thoracic  and abdomindl aorta :
  Bronchial arteries. In some cases there
is only one bronchial artery, which divides
into a right and a left branch.  Occasion-
ally there  are three or four.   The  right
bronchial artery arises so often from one
of the right aortic intercostals, that  Hal-
ler observed this arrangement  in thirteen
instances out of twenty-five.  It is,  more-
over, not unusual for one  of these vessels
to arise from the internal mammary, the
inferior thyroid,  the innominata, or the
subclavian.  In some cases of morbus cse-
rulius, the bronchial arteries  have  been
found preternaturally enlarged.  (Jacob-
son.   Meckel's Archiv. fur Physiol.  II.
134.   Tiedemann,  Zeitschrift  fur  Phy-
siologie, I. 111.; and Otto,  Lehrbuch der
Path. Anat. I. 312.)
  Intercostal arteries.  The chief varie-
ties of the intercostal  arteries  consist in
the diminution or increase of the number
of those which arise  from the aorta, ac-
cording as the  intercostal  ramulus fur-
nished by  the  subclavian, supplies  two,
three, or more intercostal spaces.  Some-
times, moreover,  two intercostal arteries
arise  by a common trunk, which after-
wards divides.
   Phrenic arteries.  These vessels  are
very liable to  vary in their  origin.   In
twenty-one cases examined by  Haller
(Icon. Anat.  Fasc. iii. p. 53.), the phrenic
arteries arose by a common trunk from
the aorta,  in three: in the same manner
from the coeliac, in two; and in sixteen,
the two vessels had a separate origin.   In
six of these, both arteries arose  from the
cceliac; in two,  from the  aorta.  In two,
the cceliac artery furnished the  right;—
the aorta the left.  In two, the right arose
from the coronary artery of the  stomach;
the left from the aorta.  In two, the aorta
furnished  the right;  the  coeliac  the left.
In one, the right arose from the emulgent;
the left from the coeliac: and in one, there
were four phrenic arteries, two  of which
took their origin from the aorta,  and two
from the  cceliac  artery.  Lieutaud saw
one  case,  in which the right phrenic took
its origin from  the first  lumbar artery;
and  in  an instance observed by Green,
the phrenic arteries arose by a  common
trunk above the  diaphragm, which  de-
scended through  the aortic foramen, and
divided  into two branches.   He  also saw
the left phrenic  detached  from the aorta
below  the superior mesenteric;  and  in
another example, there were three phre-
nic arteries; one  from the aorta, on the
left side;  on the  right, a common trunk
from the renal, divided into right and left
phrenics.  (Op.  Cit. p. 24.)
   Cceliac  artery.   In some cases, the co
lia axis is wanting,  the  three  branches
into which it usually divides taking their
origin separately from the  aorta. (Otto.
Seltene beobachtung. 1.101.)  Sometimes
the coronary artery of the stomach forms
a common trunk with one  of the phrenics,
which arises from the aorta.  Not unfre-
quently the same artery furnishes the left
hepatic  ramulus, while the right arises
from the  coeliac  or superior mesenteric.
An example of the last variety has been
reported by Meckel.  (Handb. der Path.
Anat. II.  121.)  In such cases, the coeliac
artery only furnishes two branches. Some-
times there are two hepatic arteries,—one
from the coeliac, the other from the aorta.
In addition to these two, there  may be a
third from the superior mesenteric artery.
Occasionally,  the  trunk  of the  hepatic
artery proceeds directly  from the aorta 
                          ARTERIES.

 (Meckel), or from the  superior mesen-
 ric artery (Haller).  Green also reports
 a case, in which there were three hepatic
 arteries;—one  from the cceliac,  in com-
 mon  with the  coronary  of the stomach;
 a second from the same artery, in common
 with  the right gastro-epiploic; and a third
 from  the superior mesenteric, which gave
 off the cystic  artery.  In one case,  the
 coeliac artery divided  into four branches,—
 the three which are natural to it and the
 right gastro-epiploic  artery, the latter of
 which,  about  an  inch  from its  origin,
 united with a branch of the hepatic ar-
 tery, so as  to  form with it a right-angled
 triangle.   (Weber,  in  Hildebrandt's
 Handbuch der Anat.  III. 230.)  Another
 anomaly of this kind  is that in which the
 coeliac furnishes the  superior mesenteric
 artery.  In a case reported by Petsche,
 the coeliac  divided into three branches,
 but that which corresponded to the he-
 patic artery was distributed to the right
 renal capsule,  and the liver was supplied
 by the superior mesenteric.  In some in-
 stances, a small branch  of the emulgent
 artery is expended upon the liver. Mills
 has reported a case in which the hepatic
 artery was wanting.   (Green. Loc.  Cit.
 p. 25.)
   The superior mesenteric artery.   This
 artery sometimes  arises from the coeliac,
 as was  remarked above;  and not unfre-
 quently it comes  off so near that vessel,
 as to present the appearance of a common
 origin.  Velse reports  a  case,  in which
 the superior mesenteric artery was double,
 one branch  taking its origin directly be-
 low the other.  (Hallkr. Diss. Anat. VII.
 155.) In a monster which was examined
 by Wehrde, the superior mesenteric, sa-
 cro-medial,  and the left umbilical arteries
 were wanting.  (Dissert,  anat. path, de
 monst., &.c.  Hate, 1826.)  In a case ob-
 served by Vicq D'Azyr, there was no an-
 astomosis between the  superior and infe-
 rior mesenteric arteries.
   Emulgent arteries.  Varieties of these
 arteries are of frequent occurrence.  They
 consist, for  the most part, either in an
 increase in  number, or an unusual origin
 of one  or both  vessels.  The number is
 sometimes increased by the emulgent ar-
 tery  dividing  into more branches than
 usual before it enters  the kidney;  but
 cases are not uncommon, in which there
 are from two to five emulgent arteries, for
 one or both glands, which take  their ori-
gin separately  from  the aorta  or  some
other  vessels.  Eustachius has  figured
several examples of this anomaly (Tab.
Anat. Tab. xii. figs. 9,10,11.), and many
(Special Anat.)                      363

 others have been since reported by differ-
 ent individuals.  The supernumerary ves-
 sels may all arise  from the  aorta, or  in
 part from it and the common  iliac, the in-
 ternal iliac, or the middle sacral.   In one
 of the cases figured by Eustachius, both
 kidneys  received  three arteries, two  of
 which had their  origin  from  the aorta
 some distance  apart, whde the third pro-
 ceeded from the left common iliac.  It is
 more particularly when the kidney is situ-
 ated  lower down than  usual, that these
 accessory  emulgent  arteries are apt to
 take their origin below the ordinary point.
 Two cases were observed by  Otto (Path.
 Anat. p. 312.),  in which an emulgent ar-
 tery arose from the middle sacral artery;
 —in one on the right, and in  the other on
 the left side. Another instance is reported
 by  Boinet, in  which the right kidney,
 placed transversely within the pelvis, had
 the  middle sacral artery distributed to it.
 (Archives Generates. Fev. 1835.)  A still
 more singular  anomaly was  furnished by
 a case  observed by Portal: both emul-
 gent arteries had  their origin by a com-
 mon trunk from the anterior part of the
 aorta.  This divided  into a right and left
 branch,  each of which proceeded to  its
 proper point of destination. (Cours d?Anat.
 Medicale. III.  290.)   In many  instances
 in which there are supernumerary emul-
 gent arteries,  some of them do not enter
 the hilus of the gland, but plunge directly
 into some part  of its surface.
    The  spermatic arteries vary consider-
 ably in their origin.   Very often one  of
 them arises from the aorta  much lower
 than the other.  They occasionally pro-
 ceed from that  vessel by a common trunk;
 and not unfrequently one of them arises
 from the emulgent  artery.  Sometimes,
 also, one of them proceeds from the cap-
 sular artery (Haller), from  the external
 iliac, the hypogastric (Mayer. Beschreib.
 des Blutgef. p. 180.), one of the lumbar,
 or even the epigastric (Meckel).  In some
 instances the spermatic artery is double,
 upon one or both sides. (Haller, Mor-
 gagni, Hunter, Pohl, Nicolai,  Huber,
 Otto.)   This happened in two cases ob-
 served by Otto, in both of which each ar-
 tery was double. (Seltene Beobacht. 1.101.)
   Lumbar arteries.  The principal  ano-
 malies of the lumbar arteries consist  in
 the origin of two or more of them  by a
 common  trunk.   In some cases, when the
 inferior intercostal artery is very large, it
 supplies the place of the first lumbar; and
 in like  manner,  the inferior lumbar  is
 sometimes furnished by the ilio-lumbar.
   Inferior mesenteric.   This artery  is 
364
ARTERIES.  (Special Anat.)
rarely wanting; yet an example has been
reported by Fleischmann (Leichenbffnun-
gen, 239.  No. 81.)  in  which  this  vessel
was absent and had its place supplied by
the superior mesenteric artery.   But the
most  singular anomaly of this  vessel  is
one described by Petsch. (Syllog. observ.
anat. select.  § 76.)  The right kidney was
wanting:  the  aorta, after  giving oft' the
left emulgent artery, divided into the two
primitive iliacs, from the left of which the
inferior mesenteric artery took its origin;
and below this point the two iliac arteries
were united  by a transverse branch.
Fig. 18.
   a, Aorta,  b, b, Common Iliacs. c, Internal Iliac, d. External
  Iliac, e, Ilio-lumbar. /, Lateral SanaL g, Middle Hemorrhoidal.
  A, Umbilical. •', Vesical,  ft, Obturator.  I, Gluteal,  m, Ischiadic
  n, Pudic o, Epigastric,  p, Circumflexus Ilii. q, Middle Sacral.
   W. Arteria iliaca communes. (Fig. 17.
  h.  Fig. 18. b.)   The  common, or primi-
  tive  iliac arteries, are  two large vessels
  formed by the bifurcation of the  aorta, at
  the inferior margin  of the fourth lumbar
  vertebra.  They separate from each other
  at  an acute angle,  and supply the whole
  of  the parts  within  and  exterior to the
  pelvis, as well  as  the lower extremities.
  In  the female, the angle formed by their
  separation is wider because of the greater
  dimensions of  the  pelvis;  but  in  both
  sexes, they incline  obliquely downwards,
  outwards,  and a little forwards, covered
  by  the peritoneum, until they arrive  in
  front of the sacro-iliac  symphisis, where
  they divide into a posterior and  an ante-
  rior branch  (Fig. 18. c, d.), which are the
  internal  and  external iliacs,—the first of
  which is appropriated chiefly to the organs
  and walls of the  pelvis; the second to the
  lower extremities.   The  tv/o  primitive
  iliac arteries, though  of equal size, differ
  somewhat  in their  relations.   They are
'  both placed behind the peritoneum,  and
  crossed obliquely by the  ureters, as the
  latter descend into the pelvis.  They like-
  wise have the psoas muscles  upon their
outer side and a  little posterior.  The
right iliac is  a  little  longer and  more
curved than the left, because of the situa-
tion of the bifurcation of the aorta to the
left of the middle line of the vertebra.  It
is crossed by the lower part  of the ileon,
where it is about to join the ccecum, and
the vermiform process is in front of it. In
its  course, it  glides in front  of the com-
mencement of the cava, and of the left
iliac vein, which is placed posterior, and
to the left of the  artery.  The left iliac
has the termination of the  sigmoid flexure
of the colon  and the commencement of
the rectum in front and the left iliac vein
inwards  and  posteriorly.   It  pursues a
straighter course than the right, and, con-
sequently, ranges  more in  the direction
of the axis of  the aorta.  Neither of them
furnish any branches previous to their di-
vision into the internal and external ili-
acs, with the  exception of some very mi-
nute ones to  the peritoneum, glands, cel-
lular tissue, and other adjacent parts.   A
branch, however, comes off in the  bifur-
cation of the  aorta, which descends mid-
way between  these vessels,  and must be
described previously  to tracing out the
distribution of the  internal Uiac. It is de-
nominated
  X. Arteria sacra media. (Fig. 17. e. Fig.
18. q. Fig. 21. b.) At its origin, it is nearly
as large as one of the 1 uuibar arteries. It de-
scends along the middle of the anterior face
of the sacrum, to the extremity of the coc-
cyx, having the rectum and superior he-
morrhoidal artery in front   At its termi-
nation, it reflects a small branch outwards
on  each side, which, anastomosing with
similar branches  of the lateral  sacral,
forms a kind of vascular arch on the right
and left sides, and in front of the coccyx.
In its course,  the middle sacral  artery dis-
tributes  small branches to   the  rectum,
which anastomose with  the  hemorrhoidal
arteries; and  besides these, several others
which range   outwards transversely,  in
front of the several segments of the bone,
and near the anterior sacral  foramina, an-
astomose with similar branches from  the
lateral sacral arteries.   Small branches
also penetrate these foramina, to supply
the  sacral nerves; others are distributed
to the substance of the bone; and the up-
per  transverse branch generally anasto-
moses with the ilio-lumbar, and  sometimes
supplies  the  place of one of the lumbar
arteries.
  Y. Arteria iliaca  interna, s. hypogas-
trica. (Fig. 17. r. Fig. 18. c.)  The relative
size and the distribution of this artery.differ
so much  in the foetus and  the adult that 
ARTERIES. (Special Anat.)
365
it will be proper to describe the arrange-
ment it presents at both these periods of
life.
  In  the  adult it  descends in nearly a
perpendicular direction in front of the sa-
cro-iliac  symphises, from the upper part
of  that articulation to the  sacro-sciatic
notch, where it seems to terminate by  di-
viding into branches.  Very commonly,
however, shortly after its origin it resolves
itself into two principal divisions,—one
anterior, the other posterior, from which
all the other branches derive their origin.
When this is  the  case, the anterior fur-
nishes the  ischiatic, internal pudic, hemor-
rhoidals, uterine, vaginal, vesical, and um-
bilical branches; the posterior, the  ilio-
lumbar, lateral sacral, gluteal, and  obtu-
rator.  In its course, the internal iliac ar-
tery has its corresponding vein; the  com-
municating branch  of the  lumbar plexus
of  nerves  and  the  pyriform muscle be-
hind ; the sacral plexus of nerves upon its
inner side; the psoas muscle on its outer
side,  above; and the ureter  ranging ob-
liquely in front of it near where it  sepa-
rates from the external iliac.  Its branches
are numerous,  and  exceedingly irregular
in their origin.
   a.  Ramus ilio-lumbalis.  (Fig. 18.  e.)
The ilio-lumbar branch is the first of any
importance given off by the internal iliac
artery.  It arises from  the  posterior part
of that vessel,  in front of the  sacro-iliac
symphisis, and proceeding outwards, back-
wards, and slightly upwards,  behind the
psoas muscles and the external iliac ves-
sels,  and  in front of the  communicating
branch of the lumbar plexus of nerves, it
divides on a level  with the base of the
sacrum,  into  ascending  and  transverse
branches.
   The  ascending  branches  mount up-
wards, distributing  ramifications  to the
psoas, iliacus internus, and quadratus lum-
borum muscles.  It also sends some small
branches through the intervertebral fora-
mina, to the cauda equina, and forms a
free anastomosis with the last lumbar  ar-
tery.
  The external branches are  superficial
and deep-seated.  The first pass outwards
between  the peritoneum and the iliacus
internus,  sending  ramifications  to  both
these parts, as well  as to the psoas:  some
of them reach the crista of the  ilium, and
terminate there in  the broad muscles  of
the abdomen.   The deep-seated ramify in
the substance of the iliacus internus, and
supply the periosteum: one of them pene-
trates the nutritious foramen of the bone,
to  supply its  reticulated texture.  Some
                 31*
of them advance along the crista of the
ilium, and anastomose freely with the cir-
cumflexus  ilii  and the gluteal arteries.
Sometimes a few branches also descend
along the psoas and iliacus internus  mus-
cles, to the vicinity of the  crural arch,
and anastomose with the epigastric  and
obturator arteries.
  b. Ramus sacri lateralis.  (Fig. 18. f.)
The lateral sacral artery generally con-
sists of a single small branch;  but some-
times there are two or more,  which run
parallel with each other. It usually arises
from the inner part  of the internal  iliac,
but occasionally  from  the ilio-lumbar or
the gluteal.  It descends along the ante-
rior face of the sacrum, in  the direction
of the line  of the anterior sacral foramina,
and about an inch from the middle sacral,
with which it runs parallel.   Converging
slightly towards the centre as it advances,
it reaches the coccyx, and there turns in-
wards, to anastomose in form  of an arch
with  the  middle  sacral,  and  the corre-
sponding branch of the opposite side.  It
is placed in front of the pyriform muscle,
and  the roots  of the  sacral  nerves, to
which it gives small branches: it  like-
wise  distributes  several small ramuli to
the anterior  face of the  sacrum, which
supply the  periosteum  and sacral ganglia,
and anastomose with the ramifications of
the middle sacral.  Posteriorly,  it gives
off a branch for each anterior sacral fora-
men, which having penetrated its proper
opening, divides into  an anterior and a
posterior ramulus.  The first is expended
upon the sacral canal and the cauda  equi-
na ; the second proceeds backwards through
the posterior sacral foramen,  and is distri-
buted to the deep-seated muscles of the
back.
   c.   Ramus   hamorrhoidalis  medius.
(Fig. 18. g.)  This  is generally a small
and irregular branch, which proceeds as
often  from  the gluteal, or the ischiadic, as
from  the   internal iliac.  It runs down-
wards and forwards, between the rectum
and bas fond of the bladder in the male,
and between the  former  and the vagina
in the  female.   It distributes  numerous
small branches  to these parts, to the vesi-
cute  seminales,  and the  prostate gland.
Some are  likewise reflected upwards, to
anastomose with the superior hemorrhoidal
branch from the inferior mesenteric; while
many others form free inosculations,  near
the anus, with  the inferior hemorrhoidal,
which arises from the internal pudic.
  d.  Ramus umbilicalis.  (Fig- 18. h.)
The condition of this branch is very dif-
ferent  in the foetal state from that which 
366
ARTERIES.  (Special Anat.)
it  assumes  after birth.   In  the first it
seems to be the continuation of the inter-
nal iliac artery, which turns upwards,  for-
wards, and inwards,  along  the superior
lateral part of the bladder;—thence taking
its  course obliquely  upwards, along  the
posterior  face of the abdominal muscles,
invested  in a  fold of the peritoneum, it
meets its fellow at the umbilicus, and both
of  them  passing  through that  opening,
pursue their course  along the umbilical
chord to the placenta.  At this period of
life, therefore, where it  ascends by  the
side of the fundus of  the bladder, it forms
an arch with its convexity looking down-
wards, from which the principal branches
distributed to the pelvic organs take their
origin.
  After birth, the relative size of this ves-
sel  undergoes a very striking diminution,
and all that portion of it between the fun-
dus of the  bladder and the umbilicus be-
comes  obliterated, and is  converted into a
round  compact chord, denominated  um-
bilical ligament, which is  contained within
a duplicature of the peritoneum. The only
branches  it furnishes at  this  period are,
the superior vesical branches to the  fun-
dus of the bladder, and in the female, a
few to the uterus.
  e. Rami  vesicales.  (Fig. 18.  i.)  The
vesical arteries are exceedingly variable
as to number,  and the source from which
they have their origin.  The bladder, in-
deed, receives blood from several sources,
as the pudic, the  obturator, hemorrhoidal,
and other arteries: but besides these, it
has others  which are for the most part
proper to  it.  These  may be divided into
superior and inferior.
  The  superior  vesical branches  arise
from the  umbilical artery where  it  ad-
vances along the side of the fundus of the
bladder.   They ramify extensively  upon
the adjacent portion  of that organ, some
of them descending towards its neck.
  The inferior vesical branch generally
arises from the internal  iliac, but some-
times from the gluteal or  ischiatic.  It  fol-
lows the  course of the ureter, glides be-
tween  the coats of the lower fundus of
the bladder near where  that  tube pene-
trates it, and expends itself upon  the neck
and adjacent portion of the organ, the  ve-
siculae  seminales, vas deferens, prostate
gland, and the neighbouring  part of  the
rectum.
  f. Ramus uterinus.  The size of  the
uterine artery varies  at different periods
of life, and is especially influenced by  the
condition of the organ itself  During child-
hood it is relatively small;  bat when  the
uterus takes on  its proper functions, at
the age of puberty, and especially in its
impregnated state,  it becomes very large,
and exceedingly tortuous in its distribu-
tion.   It arises from the internal iliac ar-
tery—sometimes from the umbilical,  glu-
teal,  ischiadic,  pudic,  or  hemorrhoidal
branches  of that vessel.  Inclining  for-
wards by the side of the upper part of the
vagina, it sends branches to that organ,
to the adjacent portion of the bladder, and
the mouth of the uterus: it then engages
itself between the fold  of the  broad liga-
ment, runs in a tortuous direction towards
the organ it  is  intended to supply,  into
which its branches plunge and ramify ex-
tensively, forming at the same  time a free
anastomosis with their fellows of the op-
posite side.  Other branches  are  distri-
buted to the Fallopian tubes  and ovaria,
and inosculate freely with the spermatic
artery.
   g.  Ramus vaginalis. This is generally
a  small branch,  and not unfrequently its
place is supplied by some other. Like the
preceding, it may arise either from the
internal iliac, the ischiadic, pudic,  or he-
morrhoidal.   It descends upon the ante-
rior lateral  part of the vagina, supplying
numerous branches to that organ and the
neighbouring parts of the bladder and rec-
tum.  Having arrived at the external parts
of generation,  it is  expended upon them,
and forms there an extensive anastomosis
with the internal pudic artery.
   h.  Ramus  obturatorius.   (Fig. 18. k.)
The obturator  artery, though constant in
its existence, is far from being so as re-
gards  its origin.  Proceeding most  fre-
quently from the internal iliac, cases are
not rare in which it arises either from the
gluteal, ischiadic, epigastric, external ili-
ac, or even the femoral artery.   When it
is  a branch of either of the last named
vessels, its course and relations are mate-
rially changed ;—it  descends in nearly a
perpendicular direction to reach the obtu-
rator foramen, and as it runs in the imme-
diate  vicinity  of the crural ring,  it will,
when such  a distribution  exists,  in the
event of a hernia being produced, course
around either  the  posterior internal, or
the anterior parts of the neck of the  sac.
(See Abdomen, Surg. Anat and Varieties
of the present head.)
   When the obturator artery arises from
the internal iliac, it courses downwards,
forwards,  and outwards, along the inner
surface of the  lateral wall of  the pelvis,
and a little behind  the obturator nerve,
with which it advances towards the' upper
portion of the thyroid foramen.  It then 
ARTERIES. (Special Anat.)
367
 glides over the obturator internus muscle,
 and in company with  the  nerve passes
 through a small round aperture in the up-
 per portion of the obturator ligament after
 which it immediately divides into two se-
 ries of branches,—the  one  posterior,  the
 other anterior.   In its course to this point
 the artery gives a small branch outwards,
 which twines over the brim of the pelvis,
 and is expended upon the iliacus  internus
 muscle: others of small size, to the blad-
 der, prostate,  obturator muscle,  and  the
 neighbouring lymphatic glands;  and one
 which mounts upwards along the posterior
 face of the symphisis pubis, where  it sends
 ramifications across to anastomose with
 the vessel of the other side,  and a few
 which take their  course outwards, to in-
 osculate,  near  the crural ring, with the
 branches  of the epigastric.
   The posterior branches of the obturator
 artery course along the external  margin
 of the  thyroid foramen,—sometimes  be-
 tween the two  obturator muscles,  but  oc-
 casionally over the surface of the exter-
 nal.  They send numerous  ramifications
 to these muscles and to the adductor mag-
 nus : some glide through the notch of the
 acetabulum, to supply the structures with-
 in that  cavity; but the chief branches
 wind round between  the acetabulum and
 the tuber of the ischium, to reach the pos-
 terior  part of the  hip joint where they
 terminate upon the  adjacent  structures,
 forming at the same time a free anasto-
 mosis  with  the descending  branches of
 the ischiadic.
   The  anterior,  or  internal  branches,
 which terminate the obturator, wind round
 the inner margin of the thyroid foramen,
 in the space between the adductor longus
 and the adductor brevis. They inosculate
 extensively with the ramifications of the
 internal circumflex, and supply numerous
 branches to all  the neighbouring muscles,
 some of which descend for some distance
 down the thigh, while others incline back-
 wards  towards the posterior part  of the
 member.
   i. Ramus glutaus, s. iliacus posterior.
 (Fig. 18. /. Fig. 20. a.)  The gluteal is a
 very large branch, and  in the  adult may
 be considered the continuation  of  the  in-
 ternal  iliac.  It either  arises  separately
 from the posterior portion of that vessel,
 or in common with the ischiadic.   It in-
 clines at first downwards and backwards,
 having the iliac artery and vein, and the
 lumbo-sacral nerve, in front; but when it
arrives at the level of the upper  margin
of the sacro-sciatic notch, it then  turns
backwards and outwards beneath the bone,
and between the piriformis  and gluteus
minimus muscles,  in making this sweep,
the artery forms a  curve with  its  con-
vexity downwards, and having fairly es-
caped  from  the  cavity of the pelvis, and
arrived upon the dorsum  of the  ilium,  in
the space between the gluteus medius and
gluteus  maximus, it there  divides  into
a superficial and  a deep-seated branch.
While  in the pelvis,  however, it distri-
butes several small branches  to  the pyri-
form, obturator, and  levator ani muscles,
and sometimes gives origin to some of the
branches already described.
  a.  R. superficialis (Fig. 20. i.) is the
smaller of the two.  It runs outwards and
upwards between  the gluteus  maximus
and  medius, sending  in the first  place
several small branches to the  sacro-sciatic
ligament the adjacent portion of the sa-
crum, the coccygis, and the lower part  of
the longissimus  dorsi muscle:—some  of
these anastomose with the ischiadic and
pudic branches.  The superficial ramulus
then pursues its course between the glu-
teus maximus and medius, and  is chiefly
expended upon them.
  f3. R. profundus.  (Fig. 20. c.) This is
the principal branch  of the gluteal artery;
and it ramifies so extensively as  to supply
all the parts upon the dorsum  of the ilium.
It first sends one or two nutritious ramus-
culi which penetrate the  substance of the
bone: then it generally divides into three
Beries of ramifications, which may be de-
nominated superior,  middle,  and inferior.
The first sweep forwards with  a gentle
curve, between  the  gluteus  medius and
minimus, and towards  the anterior  supe-
rior spinous process  of the ilium. They
send numerous ramifications  to these two
muscles,and the gluteus maximus;—some
which mount upwards towards the crest  of
the ilium, to anastomose with the branches
of the  ilio-lumbar and circumflexus ilii
arteries; and, finally, several which glide
beneath  the tensor vagina? femoris mus-
cle, and anastomose with the  anterior cir-
cumflex.  The middle branches descend
upon the surface of the gluteus minimus
towards  the trochanter major:  they are
expended chiefly upon the glutei muscles,
but like the preceding, anastomose with
the anterior circumflex.   Finally, the in-
ferior, after giving branches to the gluteus
minimus, perforates its fibres  to reach the
dorsum of the bone,  where it descends  in
front of the acetabulum,  and terminates
by supplying the several  muscles in the
vicinity, and the capsular ligament of the 
368
ARTERIES.  (Special Anat.)
 hip joint.   It  also anastomoses  with the
 anterior circumflex and the ischiadic ar-
 teries.
   k.  Ramus  ischiadicus.  (Fig. 18.  m.
 Fig. 20. b.) The ischiadic artery, though
 smaller than the gluteal, maintains  more
 accurately than that vessel, the direction
 of the internal iliac.  It arises a little be-
 low the gluteal; descends in front of the
 pyriform muscle, and then inclining back-
 wards, escapes from the  pelvis between
 the lower edge of that muscle and the an-
 terior sacro-sciatic ligament and in  front
 of the sciatic  nerve.  In this portion of
 its transit it sends small ramusculi to the
 pelvic organs,  and  to the pyriform, obtura-
 tor, and levator ani muscles;—sometimes,
 indeed, it  furnishes  some of the arteries
 already described.  Having emerged from
 the pelvis (Fig. 20.  b.), it is  covered by
 the gluteus maximus muscle, and imme-
 diately divides into numerous  branches.
 One of these  takes its course backwards
 and  inwards,  perforates the  sacro-sciatic
 ligament,   and after sending numerous
 ramifications  to  the  gluteus  maximus,
 reaches the coccygis,  and is  expended
 upon the levator ani, the adeps,  and  other
 adjacent structures.  One or more branches
 descend between the trochanter major and
"the tuberosity of the ischium,  following
 the course of the sciatic nerve, from which
 circumstance they are sometimes denomi-
 nated ramuli comes nervi ischiadici. They
 descend for some distance upon the thigh,
 and  in their course give branches to the
 gluteus,  gemelli,  quadratus  femoris,  se-
 mitendinosus  and  semimembranosus,  bi-
 ceps, and  adductor magnus muscles; also
 to t'ie nerve itself, and to the integuments.
 They  inosculate freely with the circum-
 flex and perforating  branches of the femo-
 ral artery.  The  ischiadic artery, more-
 over, sends branches downwards upon the
 surface of the tuber ischii, which supply
 the  muscles and fat in the vicinity, and
 anastomose with the external circumflex
 and  the posterior  branches of  the  obtu-
 rator.
   1.  Ramus pudicus internus.  (Fig. 18.
 n. Fig. 19. a.) The internal pudic artery
 is not quite so large  as  the ischiadic.   It
 generally  arises  from the  internal iliac a
 little below the origin of the vessel just
 mentioned—sometimes  in common  with
 it in  which case the  trunk which fur-
 nishes the two branches  may not divide
 until it has escaped from the pelvis.  The
 artery descends at first in nearly a per-
 pendicular direction, in  front of the sacral
 plexus of neTves,  and  in  company  with
the ischiadic artery, which is a little pos-
terior.   It glides from  the  pelvis below
the inferior margin  of the pyriform mus-
cle, reposes for a small  distance upon tlie
posterior face of the 6pine of the ischium
and the attachment of the anterior sacro-
sciatic  ligament,  then  turns  forwards
through the lesser sciatic  notch, between
                 Fig. 19.
 a, Internal Pudic.  b, Inferior Hemorrhoidal,  c Superficial Pe-
rineal,  d, Transverse Perineal.
the  anterior and posterior  sacro-sciatic
ligaments, to re-enter the pelvis, thus de-
scribing  an  arch the concavity of which
embraces the spine of the ischium.  Hav-
ing made this  turn, it  courses along the
inner surface of the tuber of the ischium,
only separated from the bone by the inter-
nal obturator muscle, and is  bound down
by the strong obturator  or perineal fascia.
Thence  it mounts upwards and forwards
along the inner side  of the  ramus of the
ischium  and pubis, to the vicinity of the
lower  margin of the  symphisis, where it
terminates by dividing  into  two branches
—the  ramulus corporis cavernosi penis,
and  the  ramulus dorsalis penis.
  The first portion of  the internal pudic
artery,  which  is  contained within the
cavity of the  pelvis,  distributes  small
branches to the  bladder, prostate gland,
vesicute  seminalis, and rectum,—to the
vagina in the female, and to the pyriform
and obturator muscles.   In some cases it
likewise  furnishes the  middle hemor-
rhoidal.
  The second  portion,  which is  exterior
to the pelvic cavity, and posterior to the
spine of the  ischium, sends only a few un-
important branches to the internal obtura-
tor  and gemelli muscles, and other parts
in the  vicinity.
  The third portion is more  important on
account  of its liability  to be wounded in
the operation of lithotomy where  it runs
along the inner side of the tuber ischii
Besides  some small  branches which it
sends outwards  to the  flexor muscles of
the thigh, and inwards to the parts within 
ARTERIES. (Special Anat.)                      S69
 the pelvis, it distributes several of larger
 size to the perineum, which  may be enu-
 merated as follows:
   a.  R.  hamorrhoidales inferior, s. ex-
 terni. (Fig. 19. 6.) These small branches
 are detached from the internal pudic im-
 mediately after it has re-entered the pel-
 vis, and while it reposes upon the inner
 side of the tuberosity of the ischium. They
 perforate the deep-seated perineal fascia,
 plunge through the bed of fat that fills up
 the deep  excavation  between the tube-
 rosity of  the  ischium and the anus,  and
 are chiefly expended  upon  the sphincter
 ani, and the  adjacent parts of the perine-
 um, though some of their ramifications go
 to the coats of the rectum, and anastomose
 with the middle hemorrhoidal artery.
   /3. R. perinai superficialis (Fig. 19. c.)
 is larger and more regular than the pre-
 ceding, immediately in front of which it
 takes  its  origin.  It perforates the deep-
 seated perineal fascia, and takes its course
 forwards  and inwards, in the depression
 between the erector penis and accelerator
 urina?,  sometimes above,  and sometimes
 below the transversus perinaei muscle.  In
 the first part  of its transit, it is deep-seat-
 ed,  and is placed nearer the ischium than
 to the  raphe  of the perineum; but as it
 advances, it becomes more superficial, and
 inclines towards the  median line.   It dis-
 tributes small  branches to the sphincter
 ani, the integuments of the perineum, the
 transversus perinaei, the accelerator urinae
 and erector penis, and to the  parts in the
 vicinity of the ramus of the ischium  and
 pubis. The last anastomose with branches
 from the femoral artery. The vessel finally
 reaches the posterior part of the scrotum,
 on which it  terminates by  dividing into
 numerous ramifications, one  of which is
 distributed to  the septum, and is  denomi-
 nated r. sepli scroti.
   y. R. transversus perinai.  (Fig. 19. d.)
 This is a smaller branch than the preced-
 ing, in front of which it takes its origin
 from the  pudic—sometimes,  indeed,  in
 common with the perineal branch.  It per-
 forates  the deep-seated fascia, advances
 obliquely across the perineum, along the
 cutaneous surface of the transversus peri-
 naei  muscle, and having reached the me-
 dian line, sends branches  backwards to
 the sphincter ani, which anastomose with
 the  external  hemorrhoidal ramuli,—and
 others  forwards, to the muscles and inte-
 guments of the perineum, which anasto-
mose with the  superficial  perineal ramu-
lus, and with  the vessels of the opposite
side.  This branch is generally divided in
making the first incision in lithotomy.
   8. R. corporis bulbosi, s. spongiosi ure-
thra.  This  is  a  considerable branch,
though much shorter  than either of the
preceding.  It arises from the internal pu-
dic after it has reached the crus penis, and
taking its course horizontally outwards,
towards the bulb of the  urethra, it keeps
above  the deep perineal fascia, and after
passing a short distance,  divides into two
branches.  One of these, of small size, de-
scends and is expended upon  Cowper's
glands, while  the other, much  larger,
plunges directly into the bulb, and rami-
fies throughout  the whole spongy portion
of the urethra as far  as the glans penis,
and besides, sends branches into the  cor-
pus cavernosum, and the muscles and in-
teguments.
   e, R. corporis cavernosi,  s. profundus
penis.   The ramulus  of the corpus ca-
vernosum is one of the  two branches by
which the  internal pudic artery termi-
nates.  It comes off immediately after that
vessel has perforated the triangular liga-
ment of the urethra, and where it reposes
between  the  bone  and  the crus  penis.
Penetrating the  latter body obliquely,  it
ramifies most minutely through the whole
extent of the corpus cavernosum, passing
forwards nearly through its middle, and
sending   anastomosing  branches  across
through  the septum, numerous ramifica-
tions to the lining membrane of the  ure-
thra, and some which perforate the fibrous
envelope  of the corpus  cavernosum, to
supply the integuments  of the penis.
   n. R. dorsalis penis (Fig. 21. o.) glides
in the space between the crus and the
arch of the pubis, then perforates the sus-
pensory  ligament  and  takes  its course
superficially along the dorsum of the pe-
nis, accompanied by  its fellow and the
corresponding veins.   Its course is  tortu-
ous, and  it forms frequent  anastomoses
with its  companion.   Near  its origin,  it
sends ramifications to the anterior part of
the scrotum and adjacent parts; and in its
course it supplies the integuments of the
penis, and sends  some branches into the
corpus cavernosum.  Arrived at the  pre-
puce, a free anastomosis is there formed
between  it and its fellow, and part of the
ramifications are expended upon that fold
of the  skin, while others plunge  into the
glans.
   In the  female, the  superficial perineal
artery, after supplying the parts  in the
perineum, and the constrictor muscle of
the vagina, terminates  in the labia.   The
pudic itself, near the  arch of the pubis,
divides into two branches, which are dis-
tributed upon the clitoris, the one coursiug 
370
ARTERIES.  (Special Anat.)
along superficially upon its dorsum (r. dor-
salis  clitoridis), the other plunging into
the central portion of that body, in which
it ramifies like the ramulus  of the corpus
cavernosum.
  Varieties of the Internal Iliac Artery
and its branches:
  The median sacral artery does not pro-
perly belong  to this place.   But as we
have described its natural distribution un-
der the present division, we shall pursue
the same course in noting its varieties.
The distribution of this vessel to the kid-
ney has been  already mentioned.  In ad-
dition to this anomaly, it sometimes varies
in its origin.   Green remarks that he has
several times seen it arising from one  of
the lumbar arteries.  In some instances it
arises from the ilio-lumbar,  and occasion-
ally from the primitive iliac.
  Bio-lumbar artery.  This branch arises
sometimes  from the primitive iliac,  the
femoral,  or the gluteal  artery.  (Tiede-
mann.)   In a few instances it  takes  its
origin by a trunk  common to it  and the
middle sacral; and occasionally its place
is  supplied by two small ramuli.  (Tiede-
mann.)   Green remarks that in one  in-
stance he observed the ascending branch
of the ilio-lumbar arising from the primi-
tive diac.
  The lateral sacral artery  is sometimes
double;  and   in such eases  one branch
generally takes its origin from the inter-
nal iliac, the  other  from the gluteal, ilio-
lumbar,  or  ischiadic artery.   (Hilde-
brandt, Tiedemann.)  Occasionally there
are as many as five ramuli communicating
freely with each other (Green),  and in a
few instances it has  been  seen arising
from the primitive iliac.  (Tiedemann.)
   The gluteal artery.  The principal va-
rieties of this artery consist in its arising
in common with one or  more of the ves-
sels usually given off by the  internal iliac,
or in the origin of some  of  them from it.
Thus it sometimes comes off with the is-
chiadic, or pudic, or middle hemorrhoidal;
or it furnishes one or more of those vessels.
  The  ischiadic,   middle  hemorrhoidal,
vesical, uterine, and vaginal arteries, vary
m their origin  like  the gluteal; but as
their anomalies present nothing peculiar,
they need not be described.
   Umbilical arteries.  Two cases are  re-
ported by  Otto  (Seltene Beobacht. und
Path. Anat.) in which the umbUical arte-
ries of the right and left sides united with-
in the abdomen into one trunk, which was
contained within a fold of the peritoneum
of about an inch in breadth.   A similar
case was observed by Kelch. (Beitrage
zu Path. Anat. p. 60.)  Numerous cases
have been reported in which the umbilical
artery on one side was  entirely wanting.
(Otto.  Loc.  Cit.  p. 312.)   Breschet  ob-
served an example in which one of these
arteries took its  origin  from the common
iliac.  (Reperl. d'Anat. et Physiologie. II.
471.); and in  one instance  reported by
Hottenger,  it  arose  from  the  aorta.
(Misc. Nat. Curios. Dec.  iii.  an. 9. obe.
233.)  Otto has referred to numerous au-
thorities who have  reported examples of
this anomaly. (Path. Anat.  p. 312.)  Some-
times the umbilical artery arises in com-
mon with the uterine or the  middle he-
morrhoidal. (Tiedemann.)
  Obturator  artery.  Anomalies of this
vessel are of very frequent  occurrence,
and as  under such circumstances the ar-
tery is often placed in the  vicinity of the
parts  through  which  hernias protrude,
these  irregularities are important  and
merit a careful consideration.  It has been
remarked above, that the obturator artery
not unfrequently arises in common with
some  of the  other branches of the inter-
nal diac.  Its most important varieties are
those  which  are  observed  when it arises
from  the  external ihac, the epigastric, or
the femoral artery.   Of these three ano-
malies,  the origin of the obturator in com-
mon with the epigastric, is by far the most
frequent.  Haller observed it in nine in-
stances. When it occurs,  the trunk com-
mon to  the two arteries may be from two
lines  to an inch and a half  in length.  In
thirty-two  bodies examined  by Hessel-
bach, the origin of the obturator from the
epigastric took place on the right side in
nine,  and on  the  left in  ten.   Out  of 250
subjects examined by Jules Cloquet, he
found the obturator arising from the epi-
gastric  on both sides in 56;—from  the in-
ternal iliac on one side and the epigastric
on  the  other in  28.  The origin  of this
artery directly  from the internal iliac is
less common; yet we have several times
met with it and numerous  examples have
been  reported by Lieutaud, Soemmering,
Burns,  Monro,  Cloquet, Hesselbach,
Tiedemann,  and others.   This anomaly
was observed by  Cloquet  in  six subjects
out of 250.  Portal reports a case in
which  the obturator was  formed  by  the
union of a small  branch from the internal
iliac and a larger one from the epigastric
(Cours d'Anat. Medicale.  III. 332.); and
three examples of a similar arrangement
have  been figured  by Hesselbach (Tab.
3.).   Occasionally the origin of the obtu-
rator  artery takes place from  the femoral
artery below  Poupart's ligament  and to 
ARTERIES. (Special Anat.)                       371
reach its point of destination it ascends
along the pectineus muscle, and  enters
the pelvis at  the crural  ring.  Monro,
Burns,  Otto,  Tiedemann,  and  others,
have described examples of this anomaly.
Green observed  a  case in which there
were  two obturator arteries on the  left
side;  one from the  epigastric, which was
large; the  other smaller, from the usual
origin.  They passed through the  obtura-
tor ligament  by distinct  foramina.   He
also  represents that there is a cast of a
preparation in the museum of Dr. M'Cart-
ney, in which there was no internal obtu-
rator, the muscles which  that vessel sup-
plies, receiving ramifications  from  an as-
cending branch of the profunda. The same.
author has figured an example in which the
obturator is seen arising from the femoral
artery, and as it mounts upwards,  to turn
over the pubis,  it gives off the dorsal ar-
tery of the penis. (Tab. v.  fig. 3.)
   For further observations on this subject
see Abdomen, Anat. I. 30.
   Internal pudic artery.   In some in-
stances,  this vessel,  instead of passing
through the space between the two sacro-
sciatic  ligaments, descends  directly be-
hind  the bladder, and through the pros-
tate,  to reach the penis; or if the artery
pursues its  usual course,  a  considerable
branch  may traverse  the  prostate gland.
In either case, a fatal hemorrhage might
be induced in the operation of lithotomy,
as happened  to  Mr. Shaw, of London, a
few  years  ago.  (Lond. Med. and Phys.
Journ.)  The first of these anomalies was
described by Vesalius, and  many of the
older anatomists, as the natural distribu-
tion  of the artery.  The dorsal artery of
the penis sometimes arises from the obtu-
rator artery within the pelvis. A case has
been  quoted  above, on the  authority of
Green, in which this  latter vessel  pro-
ceeded from the femora] artery below Pou-
part's  ligament and in  its course up-
wards furnished the dorsal artery of the
penis.  It sometimes arises from the com-
mon femoral (Tiedemann), the superficial
pudendal (Ibid.), or the profunda  (Ibid.).
  W. Arteria iliaca externa. (Fig. 17. i.
Fig. 18. d. Fig. 21. c.)  The division of
the primitive, or common iliac arteries, at
the sacro-iliac  junction, has been  already
described.  The  external diac, which  is
one of the great branches  formed  by this
division, may be regarded as the proper
continuation of the  main iliac, and is des-
tined to supply the whole  of the  inferior
extremity.   Like the subclavian artery, it
is designated by different appellations, ac-
cording to the  region  through which it
passes.  Thus, that portion of it which is
included between the sacro-iliac  symphi-
sis and the lower  border of Poupart's
ligament  is called  external  iliac artery.
From the  latter point to where the vessel
penetrates the aponeurosis of the adductor
muscles of the thigh, it is called femoral
artery; while a third portion, which de-
                 1%. 20.
 a, Gluteal,  b, Ischiatic c. Profound Branch of Gluteal,  t, i.
Popliteal. /, External Articular,  g, Internal Articular. A, Sural.
scends from this situation along the pos-
terior face of the member, to the inferior
margin of the  popliteus muscle, is de-
nominated popliteal artery.  There it di-
vides into two branches—the anterior and
posterior tibial arteries, which supply the
leg and foot.
  The external  iliac arteries of the right
and left side are so similar in their distri-
bution,  that the description of one will
apply to the other.  From the vicinity of
the sacro-iliac symphisis, at which point
it separates from the internal iliac already
described, the  external iliac  artery pro-
ceeds downwards and outwards,  along the
anterior internal surface of the psoas mus-
cles, to escape from the abdomen beneath
Poupart's ligament  about midway be-
tween the symphisis pubis  and the  ante-
rior superior spinous process of the ilium,
but generally from a fourth to half an inch
nearer the former than the latter. Having 
372
ARTERIES.  (Special Anat.)
emerged from  beneath the ligament and
entered the groin, it takes  the name of
femoral artery, and is there so superficial,
that it can be felt pulsating beneath the
skin, and can be readily compressed where
it glides in front of the ramus  of the pu-
bis.  In its whole course, it is invested in
a sheath  furnished  by  the  iliac fascia,
which  ties it down  to the psoas muscles.
In the upper portion of its transit the cor-
responding  vein  is  situated posteriorly,
while in the vicinity of Poupart's  liga-
ment and  where the  artery glides  over
the horizontal  branch of the  pubis, the
vein is on the inner side, and on the same
plane.   In front, it is in relation with the
peritoneum, the spermatic artery, the in-
ternal genito-crural  nerve, and the  iliac
lymphatics which twine upon its  surface.
It is also crossed on this aspect by the vas
deferens, as that vessel descends  into the
pelvis.   Posteriorly,  it reposes upon the
inner anterior  part of the psoas  muscle,
and where  it escapes from the abdomen,
it is nearly in contact with the horizontal
ramus  of the pubis.   Externally it  is in
relation with the  anterior crural nerve,
from which it is separated above by a por-
tion of the psoas muscle.
  In its course downwards, the external
iliac artery only  gives a few very small
and  unimportant  branches  to  the  psoas
muscles, glands, and adjacent parts,  until
it arrives near Poupart's ligament, where
it sends off the following:
  a. Ramus epigastricus.   (Fig. 17.  I.
Fig. 18. o.  Fig. 21.  e.)   The  epigas-
tric artery,  which  is  of  considerable
size, is destined to supply the  anterior
wall of the abdomen.  It generally arises
from the anterior internal part  of the ex-
ternal  iliac, about  a quarter  or half an
inch above Poupart's ligament though
in some instances it  is detached from that
vessel higher up or  lower down; and oc-
casionally  it arises from the  femoral ar-
tery.   At its origin,  it is placed between
the fascia transversalis  and peritoneum,
a little below the point at which the latter
membrane  is  reflected  backwards  upon
the  iliac  fossa.  When it  arises higher
than usual,  it sweeps downwards towards
Poupart's  ligament—then upwards and
inwards, forming a curve having its con-
vexity downwards.  But  when  it proceeds
from its natural point of origin, it advances
at once upwards and inwards,  behind the
aponeurosis  of the  internal oblique and
transversalis muscles, and between the
fascia  transversalis  and  peritoneum.   It
thus ascends in an  oblique direction, to-
wards a point situated nearly midway be-
tween the umbilicus and the pubiB, glides
behind the rectus muscle, the Hheath of
which it perforates upon its posterior part,
and then divides  into numerous ramifica-
tions which branch out extensively in that
muscle  and the neighbouring parts, and
anastomose freely with the internal mam-
mary, and the interior intercostal arteries.
  When the  epigastric  artery first com-
mences its ascent, it ranges along the in-
ner boundary of the internal abdominal
ring, immediately behind the vas deferens
and the spermatic artery and veins, Which
cross it in an oblique direction; and as the
vas deferens  separates at this point from
the other vessels of the chord,  and  in-
clines downwards and inwards to descend
into the pelvis, it is hooked around  the
epigastric artery on its  external, or iliac
aspect, where it crosses that vessel.  Be-
sides the spermatic  vessels, the artery has
the fascia transversalis and the aponeuro-
sis of the abdominal muscles in front:  be-
hind, it is in relation with the peritoneum,
—and upon its pubic side, it is accompa-
nied by  the  epigastric vein; and some-
times it has a second vein on its outer tide.
  In this course, the epigastric sometimes
gives origin  to the  obturator artery;—it
always  furnishes several  branches  of
smaller size  to  the neighbouring  parts.
Near  the internal abdominal  ring,  it de-
taches a small  branch,  which  descends
upon the spermatic  chord, escapes with it
through the  external abdominal ring,  and
supplies the cremaster muscle and the tu-
nica vaginalis, and  anastomoses with  the
spermatic artery.   Near the same  point
it sends a small branch inwards, which
follows the horizontal branch of the pubis,
passes behind the abdominal ring, and an-
astomoses, near the  symphisis pubis, with
its fellow of  the  opposite side.   The  epi-
gastric artery, besides, gives off numerous
branches of  small size from its external
and internal sides,  which are distributed
to the abdominal muscles; and also some
which perforate the aponeurosis to be ex-
pended upon the integuments.  It is chiefly
through the free  anastomosis between the
terminal ramifications of this artery, and
those of the  internal  mammary and the
intercostals,  that the circulation is main-
tained, when the aorta or the iliac artery
becomes obliterated.
   b.  Ramus circumflexus  ilii.  The cir-
cumflexus ilii artery (Fig. 17. h. Fig. 18. p.
Fig. 21. d.) is smaller than the epigastric.
It arises from the outer side of the  exter-
nal iliac, on a level with Poupart's liga-
ment or a few lines above that point: in
some instances  it  has a common  origin 
ARTERIES. (Special Anat.)                      373
with the epigastric.  Included in a sheath
furnished by the splitting of the iliac fas-
cia, where that aponeurosis is about to be
reflected forward  to become  continuous
with the fascia transversalis,  the artery
advances outwards towards the anterior
superior spinous process of the  ilium, in
front of the crural nerve,  and the  psoas
and iliacus internus muscle. In its course,
it sends small branches to these muscles
and to the cellular tissue of the iliac fossa,
—also,  several which pass downwards be-
hind  Poupart's  ligament  to  the upper
part of the thigh, where they anastomose
with  the  superficial external  circumflex
branch  of the  femoral artery.   Near the
spine of the  ilium, the circumflex artery
divides  into an external and an internal
branch.  The  first  glides  between the
transversalis and internal oblique muscles,
and  is  expended  upon the walls of the
abdomen.   The second follows the  inner
labium of the  crest of the  ilium, sending
branches outwards to anastomose with the
ascending ramuli  of the gluteal artery.
Having pursued this course for some dis-
tance,  it distributes numerous ramuli to
the broad abdominal muscles, and termi-
nates posteriorly by anastomosing freely
with the ilio-lumbar, inferior lumbar, lower
intercostal, and the internal mammary ar-
teries.
   Varieties of the external iliac artery
and its branches:
   Epigastric  artery.   The frequent ori-
gin of this vessel in common with the ob-
turator,  has been already noticed. It may
take place  either above or below  Pou-
part's ligament.  In one case of this kind
observed by Tieoemann, the circumflexus
ilii took its origin from  the femoral artery,
below the ligament just mentioned, and
furnished a considerable branch to the
thigh. The origin of the epigastric singly
from the external diac, higher  or lower
than usual,  is not uncommon; and several
cases  have been  observed, in which  it
came  off from  the femoral artery in the
groin.   This anomaly we have witnessed
in three or four  instances. Burns  also
observed it and  it occurred to Hessel-
bach in three subjects.   Tiedemann like-
wise observed two examples.  The origin
of the epigastric from the profunda femo-
ris is rarely observed; yet a case has been
figured  by Tiedemvnn, and a similar one
was noticed by Monro.  Green also re-
marks, that in a body which was dissected
at Trinity College, Dublin,  the  profunda
was given off above Poupart's ligament
and produced  the epigastric within the
abdomen.  A case is reported by Monro,
   vol.  11.         32
in which this vessel  took its origin from
the obturator, and passed directly upwards
and inwards to the rectus  muscle.   The
same author remarks, that it sometimes
arises from  the pudic  artery.  (Morbid
Anat. of the Stomach and Gullet, p. 123.)
In some instances the  epigastric artery
ascends along the course of the linea alba,
below the umbilicus; and a case has been
reported to us,  in which, under this  ano-
malous distribution, the vessel was wound-
ed by the  trocar in the operation of tap-
ping, and  occasioned fatal hemorrhage.
Sometimes there is  an accessory epigas-
tric  artery of small  size, which ascends
along the outer edge of the internal ab-
dominal ring, to be  expended upon  the
walls of the abdomen.  (Meckel, Hilde-
brandt.)
   Circumflexus ilii.   This artery not un-
frequently arises from the  femoral artery
below Poupart's ligament in which case
it sends ramuli to the  upper part of the
thigh.   It sometimes takes its origin in
common with the epigastric artery;—and
Monro  witnessed a case, in which it sent
a branch nearly as large as  the epigastric,
under  Poupart's  ligament  about  two
inches from the symphisis pubis, which
distributed numerous ramifications upon
that articulation, and the fat and skin over
the crural arch. (Loc. Cit.  p. 126.)
  X. Arteria femoralis, s. cruralis. (Fig.
21. m, m.)  The external  iliac artery, it
has been already remarked, takes the name
of femoral, or crural  artery, as soon as it
emerges from  beneath Poupart's liga-
ment and enters the groin.  It is here
situated superficially in the  middle  of a
triangular space,  the base of which  is
formed by Poupart's ligament, the inter-
nal limb by the pectineus  and  adductor
longus muscles, and the external by the
sartorius.  From this  point it winds down-
wards along the anterior and internal part
of the thigh, in a spiral direction, follow-
ing a deep furrow or depression, which is
bounded internally by the adductor mus-
cles, and  externally  by the vastus inter-
nus, until  it reaches  the junction of the
middle with the inferior third of the thigh.
It then engages itself in a strong aponeu-
rotic sheath formed by the tendons of the
adductor  longus  and  adductor  magnus,
which it traverses to reach the posterior
face of the member,  when  it continues to
descend under  the name of popliteal ar-
tery.  Thus the femoral artery, after re-
posing above upon the  horizontal branch
of the pubis, and in  front of the head of
the femur, from which it is  only separated
by  the  psoas muscle, twines  around the 
374
ARTERIES.  (Special Anat.)
internal face of the bone in a spiral direc-
tion, until it passes from the  anterior to
the posterior face  of the limb.  In the up-
per part  of the thigh,  it is only covered
by the skin, superficial fascia, a stratum
of lymphatic glands,  and  by  the fascia
lata.  Here, therefore, it can be most con-
veniently exposed when it becomes ne-
                 Fig. 81.
 a, Bifurcation of Common Iliacs.  b, Middle Sacral,  c, External
Iliac  d, Circumflexus Ilii.  c. Epigastric. /, Superficial Puden-
dal,  g, Division of Common Femoral.  A, Superficial Muscular.
i, External Circumflex,  k. Superficial Epigastric.  1, Profunda.
vn. Femoral,  n, Internal Circumflex, o, Dorsalis Penis, p. An-
astomoticus Magnus.
cessary to include it in a ligature.  In the
middle third of the thigh it is deeper seat-
ed, because the sartorious muscle, in wind-
ing down the anterior internal part of the
member, advances in front and overlaps
the artery as low as the point at which it
perforates the tendons of the  adductors.
Internally, the femoral artery is in rela-
tion, above, with  the pectineus muscle,
and lower down, with the adductor longus.
Where it enters  the groin, the femoral
vein is also on the pubic aspect  of the ar-
tery, but as it descends,  the vein  gradu-
ally gets upon its posterior face.   Exter-
nally, it is  in relation, at first with the
psoas muscle and the anterior crural nerve,
which  is slightly separated from  it; and
afterwards with  the vastus  internus.  In
its whole extent it is invested by a strong
sheath common  to it  and the  vein; and
throughout the middle third of the thigh,
the anterior saphena nerve courses along
its anterior external face. Posteriorly, the
artery reposes at first upon a round promi-
nence occasioned by  the  head of the fe-
mur and the psoas  muscle; but as it de-
scends, it ranges along in front of the ten-
dinous attachments of the adductor mus-
cles to the bone, and parallel with the in-
ner margin  of the vastus internus.
  The branches furnished by the femoral
artery may be divided into superficial and
deep-seated.
  a.  Ramus epigastricus  superficialis.
(Fig. 21. k.)  This is a small superficial
branch which is expended upon the ante-
rior wall of the abdomen.  It arises from
the anterior part of the femoral artery
about half an inch  below Poupart's liga-
ment and is reflected directly upwards
and inwards, in  front  of that band and the
aponeurosis of the abdomen. It gives small
ramuli to the inguinal glands and adjacent
parts, then  ascends beneath the skin in
the direction of the umbilicus,  in the vi-
cinity of which,  after  supplying numerous
small ramuli to the  integuments of the
abdomen, which anastomose with those of
the deep-seated  epigastric, it forms a free
anastomosis with the internal  mammary.
  b. Ramus pudicus superficialis. (Fig.
21. f,f)  There are generally two su-
perficial  pudendal  arteries, which never-
theless often have a common origin.   One
is superficial,—the  other deep-seated.
  The first generally arises from the in-
ternal part  of the  femoral artery, a little
below Poupart's ligament.   It proceeds
directly  inwards between  the skin  and
the fascia lata, giving srnall ramuli to the
inguinal glands, and near the spine of the
pubis, sends branches upwards  to the in-
teguments of the lower part of the abdo-
men and the mons veneris, while others
are distributed to the scrotum and root of
the penis in the male, and to the labia in
the female.
  The profound branch arises  somewhat
lower than the preceding, and sometimes
comes off from  the  internal circumflex.
It advances directly inwards, in front of
the  pectineus  muscle,  and beneath the
fascia lata—finally perforates  the  latter,
and expends itself by numerous ramifica-
tions upon the scrotum and the perineum,
where it anastomoses with the superficial
perineal artery.   In  the  female, it sends
branches to the  labia major.
  c.  Ramus muscularis superficialis, s.
circumflexus ilii superficialis (Fig. 21. h.)
is a small branch  which arises from the
outer side  of the  femoral artery, nearly
opposite  the  branch  last described.  It 
ARTERIES. (Special Anat.)                      375
ranges outwards  below Poupart's liga-
ment and parallel with it, and near the
anterior superior  spinous  process  of the
ilium divides into several ramuli, which
supply the  sartorius, tensor vagina? femo-
rie, rectus, and iliacus internus muscles,
and anastomose with the branches of the
external circumflex, the circumflexus  ilii
profundus,  and the gluteal.  It also sends
minute ramuli to  the inguinal glands, and
to the  integuments.
   d.  Ramus femoralis,  s. cruralis pro-
fundus.  (Fig. 21. I.)  If, instead  of de-
scribing the arteria profunda as a branch
of the femoral, we  were  to follow Mur-
ray, Barclay,  and  others, who described
the main trunk of  the crural  artery, be-
fore it divides, under the denomination of
cruralis communis, and the two great ves-
sels formed by its division, under  the ap-
pellations of superficial and profound femo-
ral arteries, the  description  would har-
monize better with the natural arrange-
ment of those vessels.   The arteria pro-
funda,  indeed, nearly equals the  femoral
proper in size, and differs  from it chiefly
in its  deeper situation, its destination  be-
ing the profound parts of the thigh, while
the femoral is placed superficially,  and is
appropriated,  for the most part, to the leg
and foot.
   In a majority of instances the profound
femoral artery  arises from the posterior
part of the crural,  about an inch and a
half or two inches below Poupart's liga-
ment or about midway between the pubis
and the  level  of the  trochanter  minor.
Sometimes, nevertheless,  it is given  off
below  this point sometimes above  it, and
occasionally even from the external diac
itself.  It advances  downwards and back-
wards, at first forming a slight curve with
its convexity towards the sartorius mus-
cle, but afterwards inclines inwards as it
descends.   At its origin,  it reposes upon
the lower part of the psoas  and  iliacus
muscles,  but as  it  proceeds downwards
and backwards, it ranges  in front of the
tendon of the pectineus and adductor bre-
vis near their attachment  to the linea as-
pera of the femur. Finally, near the junc-
tion of the upper with the middle  third of
the thigh, it perforates the space between
the adductor brevis and the adductor lon-
gus—sometimes the tendon of the latter
muscle, and after  traversing the  adductor
magnus,  and  supplying it with several
branches, it terminates by numerous ra-
mifications in the flexor muscles  situated
upon the  posterior part of the  thigh.  In
its whole course,  in short it twines round
the inner part  of the femur, precisely as
the superior collateral of the arm twines
round the surface of the humerus.
  In the first part of its transit, the pro-
found femoral  artery is merely  covered
by the integuments, inguinal glands, fas-
cia lata, and  cellular  tissue;  but lower
down, the superficial femoral artery and
vein are in front of it;  while posteriorly,
it  reposes upon the tendons of the pecti-
neus and adductor brevis  muscles, and is
placed in the vicinity of the bone.  It fur-
nishes the following branches:
  a. R. circumflexus externus. (Fig. 21.
i, i.)  The external circumflex artery is
a  very stout  branch at  its origin,  but
soon loses its volume by dividing into nu-
merous ramuli. It arises from the outer
part of  the profunda near  the point at
which that artery separates from the su-
perficial femoral, and sometimes from the
common crural. Proceeding directly out-
wards in a transverse direction, it runs in
front  of the psoas,  iliacus internus, and
crureus  muscles, and behind the sartorius
and rectus  femoris.  After  detaching  a
small branch  backwards,  in the vicinity
of  the  trochanter  minor, which  anasto-
moses with the internal circumflex,  and
some small unimportant muscular ramuli,
it divides into  ascending and descending
branches.
   The  ascending branches  are variable
in  number.   Most  of them proceed di-
rectly backwards and upwards, behind the
tensor vaginae femoris, and between that
muscle and the anterior part of the glu-
teus medius and gluteus minimus.  They
are expended by numerous ramusculi upon
these muscles and the  capsule of the hip
joint, and anastomose freely with the an-
terior ramifications  of the gluteal, circum-
flexus ilii, and internal circumflex arte-
ries.  One or two of them incline directly
outwards and  backwards;  perforate  the
upper part .of the vastus internus,  and
twine round the  outer  surface of the fe-
mur below the trochanter major, to  ter-
minate in the gluteus maximus, and anas-
tomose with the internal circumflex, glu-
teal,  and ischiatic arteries.
   The descending  branches  take their
course  downwards  upon the anterior ex-
ternal part of the thigh, between the vas-
tus externus,  crureus,  and  rectus mus-
cles, to the  outer part  of the knee joint,
where they anastomose with the articular
branches of the popliteal artery.   These
descending ramuli supply the integuments,
the tensor vaginae femoris, vastus externus,
crureus, and rectus muscles, and anasto-
mose with the perforating ramuli of the
profunda. 
376                       ARTERIES.  (Special Anat.)
  /3.  The  internal circumflex artery (r.
circumflexus internus)  (Fig. 21. n.)  is
larger than the preceding, and is much
deeper seated in the whole of its course
and  distribution.  It  usually arises  from
the posterior internal part of the profunda,
near  the  separation of that vessel  from
the  superficial femoral—sometimes  from
the latter vessel itself.  It winds  directly
backwards,  around the inner part of the
neck of the femur, above  the trochanter
minor, and  in the space between the psoas
and  iliacus, and the  pectineus muscles.
It is here embedded in a mass of cellular
tissue, and  near the head of the bone,
transmits a small branch (r. acetabuli) to
the acetabulum, which enters  its cavity
beneath the ligament  closing the notch,
and then following the ligamentum teres,
expends its minute ramusculi within the
joint.  The  circumflex  artery advances
in front of the obturator externus muscle,
and divides into a superior and an inferior
branch.  The first follows the course of
that muscle  to  its attachment in the di-
gital cavity of the trochanter major, where
it terminates  by numerous  ramusculi,
which twine about the neck of the bone,
and anastomose with the branches of the
external circumflex and  the gluteal  arte-
ries.  In its course, this branch distributes
numerous ramusculi to the obturator ex-
ternus  muscle,  which anastomose  with
those of the obturator artery; others to
the pectineus, gracilis, and the adductors,
and some which traverse these muscles to
reach the perineum.  The inferior branch
advances directly outwards, between the
quadratus femoris and adductor magnus,
sends  ramusculi to both these muscles,
and to the  semitendinosus  and semimem-
branosus in the vicinity of the tuber ischii.
It also distributes some to the posterior
part of the thigh,  which  follow the course
of the sciatic nerve, the gluteus maximus,
and the posterior part of the vastus exter-
nus.   Near the trochanter major, and the
posterior part of the  neck of the bone, it
forms a very free anastomosis with the
external circumflex, gluteal, ischiatic, and
superior perforating arteries.
  The free anastomosis of the two cir-
cumflex arteries, with the obturator, pu-
dic, gluteal, and ischiatic branches of the
iliac arteries above,  and with the perfo-
rating ramuli of the  profunda below, fur-
nishes a collateral circulation sufficiently
capacious to compensate for the oblitera-
tion of either the external iliac, or the
common femoral artery,  when it becomes
necessary to secure them in a ligature.
  After the profunda  has  furnished  the
two circumflex  branches, and while it is
coursing along  the  anterior face of the
tendons of the tdductor muscles, it gene-
rally furnishes  from one to four or five
branches, which pass directly backwards
to the posterior part of the thigh, and are
denominated perforating arteries.  Three
branches of this kind are generally de-
scribed.
  y.  The superior perforating artery (r.
perforans superior, s. primus) arises from
the posterior part of the profunda, a little
below the trochanter minor—sometimes
from  the  internal circumflex.   It passes
directly backwards through the aponeuro-
tic  attachment of the adductor brevis, or
in  the  space  between  the  tendon  of
that muscle and the  pectineus,  sending
branches to both; then perforates the ad-
ductor magnus, and divides into numerous
ramusculi which are  distributed to that
muscle, to the gluteus maximus, biceps,
semitendinosus  and  semimembranosus.
Above, it anastomoses with the obturator,
internal circumflex, gluteal, and ischiatic
arteries;—below, with the middle and in-
ferior perforating ramuli.
  8.  R. perforans  medius,  s. secundus.
The  middle  perforating  artery  arises
from the  profunda a little below the pre-
ceding,  and like it perforates the apo-
neurotic attachment  of the adductor bre-
vis.  It then  plunges into the  adductor
magnus, and supplies it and the other ad-
ductors with numerous ramusculi.  Hav-
ing reached the  posterior part of the thigh,
it distributes  numerous ramifications to
the flexor muscles, the gluteus maximus,
and vastus  externus.   While passing in
the vicinity  of the  femur,  it  generally ,
sends a  small nutritious branch upwards,
which penetrates the shaft of the bone in
an  oblique  direction,  and ramifies upon
the medullary  membrane.   The middle
perforating branch  inosculates  with the
same arteries  as the superior.
  t.  R.  perforans  inferior,  s. tertius.
The inferior perforating artery is much
smaller than either of the two branches
described above.  It arises from the pro-
funda on a level with the tendon of the
adductor longus, and after traversing the
aponeurosis of  the  adductor magnus,  is
distributed to the long flexors of the thigh,
after the same manner as the superior and
middle perforating arteries, with which it
anastomoses above, while below it inoscu-
lates freely with the articular branches of
the popliteal artery.
   Besides these branches, the  profound 
ARTERIES. (Special Anat.)
377
 femoral  artery furnishes  others of small
 size, to the psoas, iliacus  internus, pecti-
 neus, vastus internus, and  all the adductor
 muscles of the thigh.
   The superficial femoral artery, while it
 courses down the thigh, gives numerous
 small branches to the vastus internus, sar-
 torius, and adductor muscles; but they are
 unimportant, and do not require a particu-
 lar description.   Near its termination in
 the popliteal artery, and where it becomes
 engaged in the aponeurosis of the adduc-
 tor muscles, it gives origin to the follow-
 ing branch, which is of larger size:
   e. R. anastomoticus magnus.  (Fig. 21.
 p.)  This branch is detached from the  fe-
 moral where it enters  the aponeurotic
 sheath formed for that vessel by the ten-
 don of the adductor muscles and the fas-
 cia of the vastus internus.   It immediately
 perforates the fascia, and descends in com-
 pany with the saphena nerve towards the
 inner part of the knee, where  it divides
 into numerous ramuli, which anastomose
 with the articular branches of the popli-
 teal, and the recurrent branch of the tibial
 artery.   It likewise  sends branches out-
 wards, behind the tendon of the  rectus,
 which anastomose with  the descending
 ramuli of the external circumflex.
   Varieties of the femoral artery and  its
 branches:
   Common femoral artery. The point at
 which this vessel divides  into the  super-
 ficial femoral and the profunda, is subject
 to considerable variety, and has been dif-
 ferently  represented.   The average will
 probably be found to be,  from one and a
 half, to two inches below Poupart's liga-
 ment  Bell  has described it as  taking
 place four inches below  that point; but
 when this arrangement exists, it  should
 be regarded as an anomaly.  Haller, in
 one  case,  saw the division taking place
 where the artery is about to glide beneath
 the sartorius muscle. Cases in which the
 artery  divides higher than usual,  in the
 immediate vicinity of Poupart's ligament,
 are not uncommon.  (Otto. Path. Anat.
 p. 313.)  In some instances, indeed, the
 bifurcation takes  place within the abdo-
 men, presenting an analogy with the high
 division of the brachial artery.  This is
 said  by Tiedemann to occur oftener in  fe-
 males than in males, and in individuals  of
 short stature,  than in such  as  are tall.
 Burns observed four examples of this ano-
 maly;  Otto two; and Tiedemann  one.
 In each of the cases witnessed by Otto,
 the high  division existed  on both sides.
 This variety is important  in relation  to
operations  performed upon these vessels.
                 32*
   The circumflex arteries vary consider-
ably in  their origin.  Not unfrequently
one or both of them take their origin from
the common femoral—occasionally  from
the superficial femoral; and  in one in-
stance observed by Burns, the internal
circumflex proceeded  from the external
iliac,  and descended through the crural
ring to its point of destination.  In two
cases delineated by Green, the profunda
femoris wound round in front of the femo-
ral vein, before it made its descent  to be-
come deep-seated; and in one of these in-
stances, this vessel  furnished the epigas-
tric artery.   Otto refers to an example
in the collection of the University of Bres-
lau, in which the femoral  vein is perfo-
rated by a branch, from the profunda.
   Superficial femoral artery.   The most
remarkable anomaly of this vessel, is that
in which it divides  a little below the ori-
gin of the profunda into two branches,
which run parallel with each other through
the thigh, and again unite in the tendin-
ous sheath of the triceps. An example of
this kind was observed by Sir C. Bell, in
an individual on  whom  an  operation for
aneurism had been performed (Lond. Med.
and Phys. Joum. August  1826.), and  a
second has  been reported  by  Houston
(Dublin  Hospital  Reports.   IV.  314.).
Sometimes the femoral artery divides into
the posterior tibial  and  the peroneal ar-
tery, high in the groin.  Sandifort re-
ports an example in which this bifurcation
took place directly beneath  Poupart's
ligament (Obs. Anat. Path.  Lib. iv. 97.);
Portal met with it in the  middle of the
thigh (Cours d'Anat. Med, III. 239.); and
Zagorskey  observed  a  branch running
parallel with the femoral  artery, which
terminated below at the  internal malleo-
lus (Mem. de Petersb.  1803-6.).
  Y.  Popliteal artery. (Arteria poplitaa.)
(Fig. 20.  e, e.   Fig. 22,  a.)  The fe-
moral artery, having reached the posterior
face  of the femur by perforating the apo-
neurotic  sheath  formed by the tendon of
the adductor and vastus internus muscles,
then takes the name of popliteal artery.
From this point to where it terminates on
a level with the lower margin of the popli-
teal muscle, it descends  in  nearly a per-
pendicular direction, along  the  posterior
face  of the limb, inclining, nevertheless,
a little outwards.  In the first part of its
transit,  it is placed nearly midway be-
tween the semitendinosus and semimem-
branosus, which form the inner boundary
of the popliteal space,  and  the biceps,
which limits this region externally;—-then
along the posterior face of the knee joint, 
378
ARTERIES.  (Special Anat.)
Fig. 22.
>
between the two condyles of the femur;
and finally in the space between the two
heads  of  the   gastrocnemius  externus.
Having arrived on  a level with the lower
edge  of the popliteus muscle,  it divides
into the anterior and posterior tibial arte-
ries.  It reposes  at first anteriorly, against
the posterior face of the femur, from which
it  is slightly separated by cellular tissue
and adipose substance; then upon the pos-
terior face of the knee joint; and  finally
on the same face of the popliteus muscle.
At its commencement, it is covered to a
small extent, by the semimembranosus
muscle; but  in  the popliteal  space it is
deep-seated,  and  is
embedded  in a  mass
of adeps, which fills
up  the  interval be-
tween   the    ham-
strings, and is  inter-
posed   between the
artery  and the  apo-
neurosis  and   skin.
The  popliteal   vein
and nerve also occupy
its  posterior  aspect,
the first being in con-
tact  with the artery,
—the second more su-
perficial,  but both in-
clined   slightly  to-
wards its fibular side.
Below  the condyles
of the femur, it  is co-
vered by the gastroc-
nemius  muscle, and
near  its termination,
by   an  aponeurotic
band furnished by the
upper edge of the so-
leus.   A little  above
the knee joint  there
are likewise  two  or
three small lymphatic
glands  which repose
in immediate contact
with the vessel.
   The  popliteal artery furnishes several
small unimportant  branches to  the mus-
cles and adjacent parts; but besides these,
it gives off five of larger size, which de-
serve a particular description.
   a.  R.  articularis ' superior  externus.
(Fig.20. f. Fig. 22. b. Fig. 24. b.)  The
superior external  articular artery takes
its origin from the  outer part of the popli-
teal, immediately above the external con-
dyle.   Reposing close upon the bone, it
turns  directly outwards—then  forwards,
beneath the tendon of the biceps muscle,
and after  sending  branches to it, divides
 a, Popliteal.  b, Superior
External Articular,  c, Supe-
rior Internal Articular, d, Su-
ral.
into  two  ramuli.   The first inclines  a
little upwards,  and is  expended upon the
lower part of the extensor muscles, where
it  inosculates with the descending ramuli
of the  external circumflex.  The other
winds round the condyle to reach the pa-
tella, traversing in  its course the lower
part of the vastus externus muscle, which,
as well as the joint, and the head of the
femur, receive from it numerous ramus-
culi.  It finally ramifies extensively upon
the surface of the  patella, and inosculates
freely  with the other  articular, and  the
recurrent branches.
  b. U. articularis superior internus. (Fig.
20. g.  Fig. 22. c.  Fig. 24. c.) The place
of this  ramus  is sometimes supplied by
several branches which arise irregularly
from the popliteal  artery.   When the su-
perior  internal articular artery is single,
it  generally springs from the popliteal a
little  above  the condyle  of the femur,
though sometimes it comes off near  the
point at which that artery perforates  the
aponeurosis of the adductor muscles. Pass-
ing inwards,  it winds  round the posterior
internal part  of- the bone above the inter-
nal condyle,  glides beneath the tendons
of the semitendinosus and semimembrano-
sus—then  beneath  that of the adductor
magnus, and  divides into  several ramuli.
Some of these plunge  into the vastus in-
ternus, and anastomose with  the external
circumflex, and the superior external ar-
ticular.  Others descend along the tendon
of the adductor magnus  to  the internal
part of the  knee,  to  the structures of
which they distribute numerous small ra-
musculi.  These,  as well as  others which
ramify upon the surface of the patella, in-
osculate with the  anastomoticus magnus,
and the inferior internal articular.
   c. /J. articularis medius superior. The
superior middle articular artery is smaller
than the  preceding.  It arises from  the
anterior part of the popliteal artery, or
from the  external articular, and descend-
ing between  the two condyles, distributes
ramuli to the ligaments upon the posterior
part of the joint,  to the  adeps, and the
head of the bone.  One  or  more small
branches also penetrate the  cavity of the
joint, to supply the synovial membrane
and the crucial ligaments.
   Having descended below the level of
the  condyles of the femur,  the popliteal
artery furnishes the following branches:
   d.   R. surales,  s. musculares.  (Fig.
20. h.  Fig. 22. d.)  There  are general-
ly two Sural  arteries which arise  from
the  posterior  part  of the  popliteal  at
an acute  angle.   Each  one  descends 
ARTERIES.  (Special Anat.)                       379
towards the posterior face of the corre-
sponding head of the gastrocnemius  ex-
ternus, and both of them plunge into the
substance of that muscle, in which they
ramify as low as the point at which  its
fleshy belly terminates in the tendon com-
mon to it and the soleus.
  e. U. articularis inferior externus.  The
inferior  external articular  artery (Fig.
24. d.) arises from the outer side of the
popliteal artery below  the external con-
dyle. It turns outwards, beneath the outer
head of  the gastrocnemius externus  and
the  upper  part of  the plantaris — then
glides beneath the tendon of the biceps
and the  external lateral ligament, and di-
vides into two  branches.  One  of them
ramifies  upon the head of the  tibia, and
anastomoses with the recurrent: the other
runs along the outer margin  of the semi-
lunar cartilage,  and after sending ramuli
to the structures of the joint, mounts upon
the patella, and inosculates with the other
articular arteries.
   f. R. articularis inferior internus.  The
inferior  internal articular artery (Fig.
24. e.) arises from the  inner part of the
popliteal artery below  the  internal  con-
dyle.  It turns downwards and  inwards,
beneath  the internal  attachment of the
gastrocnemius muscle, winds round  the
inner part of the head of the tibia, and
glides between it  and the tendons of the
sartorius, gracilis,  and  semitendinosus.
Having sent small ramusculi to the parts
in the vicinity, it ascends upon the ante-
rior internal part of the knee, and inoscu-
lates with the superior articular arteries,
and the  anastomoticus magnus.  It sends
numerous ramusculi  to the head of the
tibia, and tlie structures of the joint
   Besides these  branches,  the  popliteal
sends some, of small size, to the gastroc-
nemius and  popliteus muscles; but having
reached  the inferior border of the latter,
and become engaged beneath an aponeu-
rosis pertaining to the attachment of the
soleus, it divides into the anterior and pos-
terior tibial arteries, both of which  are
expended upon the leg and foot.
   R. tibialis anticus. The anterior tibial
artery (Fig. 23. a, a.) extends from the ter-
mination of the popliteal, down the anterior
part of the leg to the ankle joint and thence
upon the dorsum of the instep, as far as the
space between the base of  the  first and
second metatarsal bones—the latter por-
tion of it being denominated arteria dor-
salis pedis.  Though smaller  than the pos-
terior tibial  artery, it  is a vessel of con-
siderable size.   From  its origin, it pro-
ceeds at first almost horizontally forward,
Fig. 23.
\
between the heads of the tibia and fibula,
and over the upper margin of the inter-
osseous ligament, upon which it glides  to
reach the anterior part of the leg.   Hav-
ing advanced thus far,  it turns directly
downwards over the edge of the ligament
and descends upon its anterior face, placed
                 at first between the tibi-
                 alis anticus and the ex-
                 tensor  communis digito-
                 ru m, after wards between
                 the  first of these mus-
                 cles, and  the extensor
                 longus pollicis.   It gra-
                 dually inclines towards
                  the tibia as it descends,
                  upon  the  surface   of
                  which  it  reposes  near
                  the  ankle joint; glides
                  beneath the anterior tar-
                  sal ligament, and  then
                  continues its course for-
                  wards upon the dorsum
                  of the instep, under the
                  name  of arteria dorsalis
                  pedis. (Fig. 23.  d.)
                    In  the   upper  two
                  thirds of the leg, the an-
                  terior  tibial artery  is
                  deep-Beated, and reposes
                  upon  the anterior face
                  of the interosseous liga-
                  ment, having the tibialis
                  anticus muscle  on one
                  side,  and  the  exten-
                  sor   communis  digito-
                  rum on the other.  In
                  the inferior third it is
                  more superficial, reposes
                  throughout a part of its
                  transit on the tibia, and
  o, Anterior Tibial,  b, is  placed between the
 Sf^Do^pi&.'t tibialis anticus  and the
 JeX^MeS.*^ extensor longus pollicis.
 Dorsalis foiiicis.       But as the tendon of the
 latter muscle inclines  inwards to reach
 the great toe, it crosses  the artery  ob-
 liquely  near the ankle joint, to  become
 placed beyond that point on its tibial side.
 The artery is besides accompanied in its
 whole  course  with  two   corresponding
 veins, between which it is placed.  It is
 also in relation  with the anterior  tibial
 nerve, which is oh its  fibular side above,
 in front about the middle  of the leg, and
 again on the fibular side below.
   While the artery is passing forwards
 through the interosseous space, between
 the two heads of the tibialis posticus, it
 detaches  small  branches to that muscle,
 and the flexor communis digitorum.   But
 the first important branch furnished by it is 
380
ARTERIES.  (Special Anal.)
  a. The recurrent artery (r. recurrens).
(Fig. 23. e.) This branch arises from the
anterior  tibial  artery  where  it  passes
through  the interosseous space.  Then
turning directly upwards it passes through
the upper  part  of the tibialis anticus, to
which it gives numerous ramuli, then per-
forates  the aponeurosis of  the leg, and
branches out  extensively upon the ante-
rior and  lateral part of the knee. It gives
ramuli to  the parts about the  joint, and
inosculates freely with the articular and
great anastomotic branches.  It is by these
anastomoses, that the circulation  of the
lower extremity is maintained, when  the
popliteal artery has been  obliterated by a
ligature.
  In  the whole  of  its course  down  the
leg, the anterior tibial artery furnishes
many small branches on each side to the
muscles  placed in its vicinity, and a little
above the  ankle, it gives off the internal
and external malleolar branches.
  b. R. malleolus internus. Internal mal-
leolar artery.   (Fig. 23. /)  This branch
arises from the anterior tibial artery about
two inches above the ankle joint. It passes
directly  inwards between the  bone and
the tendon of the tibialis anticus, descends
upon  the internal malleolus, and divides
there into numerous ramusculi, some of
which are  expended upon the joint, while
others anastomose with the  ramifications
of the posterior tibial artery.
  c. R. malleolus externus.   The exter-
nal malleolar artery (Fig. 23. 6.) is gene-
rally a  little larger than the preceding,
and arises  nearly opposite to it.   Advanc-
ing downwards  and outwards, behind the
tendons  of the common flexor of the toes
and the peronaeus tertius,  and in front  of
the ankle  joint,  it anastomoses with  the
anterior  peroneal ramulus  which  comes
through  the interosseous ligament sends
small branches to the ankle  joint and the
adjacent, portion of the tibia and  fibula,
and finally descends along  the external
malleolus to the outer part of the dorsum
of the instep, where it anastomoses freely
with  the posterior  peroneal, tarsal, and
external plantar branches.
  A. dorsalis pedis. Dorsal artery of the
foot.  (Fig. 23. d.)  It has been already
remarked,  that  when the anterior tibial
artery  advances upon  the  instep, after
having passed beneath the anterior tarsal
ligament, it takes the  name of dorsal ar-
tery of the foot.  This vessel advances
forwards and  a little  inwards, from  the
ankle joint to the posterior  extremity of
the first  and second metatarsal  bones, be-
tween which it passes down in a vertical
direction, to reach the sole of the foot In
this course, it is covered by the  short ex-
tensor of the toes,  and the aponeurosis
and integuments of the instep. It is cross-
ed obliquely in the first part of its course
by one of the tendons of the long common
extensor; but beyond that point is placed
between the  tendon of the common ex-
tensor and that of the  great toe, and re-
poses upon the surface of the  astragalus
and the  naviculare.   In its  direction, it
departs indeed but little  from that of the
anterior tibial artery, with which it is con-
tinuous ;  and should  it be necessary to as-
certain the whole  course of that vessel
with more accuracy, it will be represented
by a line  drawn from the inner part of the
head of the fibula, to the central point be-
tween the base of the first and the second
toe.
  Besides several small ramuli given off
by the dorsal artery  of the foot to  the ad-
jacent structures, it  furnishes some which
merit a particular description.
  a. R. tarsalis. (Fig. 23. c.)  The tar-
sal artery  is  not   always a separate
branch, but sometimes arises in common
with  the next   It  generally  comes off
from  the dorsal artery of the foot,  on a
level  with the articulation of the astraga-
lus with the naviculare, and advances for-
wards and outwards across the dorsum of
the tarsus, and beneath the fleshy portion
of the short common extensor of the toes.
It furnishes ramuli to that muscle and to
the articulations of the  tarsal bones, and
having arrived at the external part of the
foot, turns downwards beneath the tendon
of the peronaeus brevis, distributes ramuli
to the abductor minimi digiti, and anasto-
moses with the external plantar, the pero-
neal,  and external malleolar arteries.
  b. R. metatarsalis. The metatarsal ar-
tery (Fig. 23. g.) is  smaller than the last
and takes its origin from the dorsal artery
of the foot a little further forwards. It ad-
vances outwards and a little forwards, be-
neath  the short common extensor,  and
across the base of the  metatarsal bones.
In its course, it often forms a slight curve,
the convex surface  of which is directed
forwards; and besides branches to  the tar-
sus, the  articulations of the tarsal witii
the metatarsal bones, and the outer part
of the foot it gives off three of larger size
from  its  convex surface, which advance
directly  forwards along the three outer
interosseous  spaces, to  the  cleft of the
toes.  These are denominated intcrosseal
branches, because they supply the inter- 
ARTERIES.  (Special Anat.)
381
 osseii muscles.  Each one  of them anas-
 tomoses  posteriorly and  anteriorly with
 the perforating  ramuli of the plantar ar-
 teries, and at the anterior extremity of the
 metatarsal bone divides  into an internal
 and an  external ramusculus, destined for
 the corresponding side of each toe.  The
 most external of these small branches also
 furnishes  a ramusculus to the outer side
 of the little toe, and anastomoses with the
 external plantar artery.
   Where the dorsal artery of the  foot  is
 about to turn downwards between the me-
 tatarsal bone, it gives rise to
   c. It. dorsalis pollicis.  The dorsal ar-
 tery of the great toe (Fig. 23. h.) marches
 superficially upon  the fibular  side  of the
 first metatarsal  bone to  its  articulation
 with the first phalanx.  There it divides
 into two branches, one of which is  appro-
 priated to  the outer side of the great toe,
 —the other to the inner  side of the toe
 next to  it.  In its general  arrangement,
 it represents the type of one of the inter-
 osseal arteries.
   d.   R.  communicans.   The  communi-
 cating artery is  properly  the termination
 of the dorsal artery of the foot, or  rather
 of the anterior tibial artery.  That  vessel
 having reached the posterior part  of the
 interosseous space, between  the  first and
 second metatarsal  bones,  there  makes a
 sudden turn downwards towards the sole
 of the foot,  between the  two bones, and
 having reached that region, divides into
 an external and an anterior branch.   The
 first passes outwards  for a small distance
 between the lower surface  of the  meta-
 tarsal  bones  and  the accessory  flexor,
 where it anastomoses with the external
 plantar artery, to complete the arch form-
 ed by that vessel; the other advances for-
 wards along the outer border  of the first
 metatarsal bone,  sending ramuli  to its
 short flexor  and  abductor muscles, and
 near  the   great  toe, divides  into two
 branches, one of which supplies the outer
 border of that member, while the other is
 appropriated  to the inner border of the toe
 next to it.
   R. tibialis posticus.  The posterior ti-
 bial  artery (Fig. 24.  h, L), which from
 its size and  direction may be regarded
 as the continuation of the  popliteal ar-
 tery, descends along  the posterior face
 of the leg,  between the  superficial and
 deep-seated strata  of  muscles, from  the
 lower edge of the  popliteus to the fossa
between  the os calcis and  the  inter-
nal  malleolus, where it  glides  beneath
the  retinacular  ligament  of  the   ankle
joint,  and  the  abductor pollicis, and di-
 vides into the internal and external plan-
 tar arteries.  It is somewhat tortuous, and
 its course is a little oblique from without
 inward, corresponding to a line extended
 from the middle of the popliteal space  to
 the posterior part of the internal malleo-
 lus.   In the  upper two thirds of the leg,
 the  posterior tibial artery is  covered by
 the  gastrocnemius  and  soleus  muscles";
        Fig. 24'.       Dut  in  the  lower
                     third, it  runs along
                     the inner margin of
                     the  tendo-Achilles,
                     and is only covered
                     by  the   aponeurosis
                     which extends from
                     that tendon to the
                     edge of the tibia.  In
                     the first part  of its
                     transit   it  reposes
                     upon  the  posterior
                     tibial muscle;  but in
                     the middle of the leg,
                     it runs upon the com-
                     mon  flexor of the
                     toes,  and  is  about
                     half an inch from the
                     outer  edge of the
                     tibia.  Finally,  in the
                     inferior  third  of  its
                     course,  it   is  only
                     separated  from  the
                     bone by a little cel-
                     lular and adipose tis-
                     sue;  and where  it
                     turns  beneath  the
                     malleolus to pass into
                     the  sole of the foot,
                     it reposes upon the
                     concave surface  of
                     the  calcis.   In  its
                     whole transit  it is
  a, Popliteal. 4, Supenor Ex-   ,   a ,          ,
ternal Articular,  c, Superior In-  placed between the
temal Articular,  d, Inferior Ex-  »               j •
ternal Articular,  t. Inferior In-  tWO   Corresponding
Po^ritSaUn^ib^arAr'  VeinS,  and  the P0S-
$^'* wS^SSSS  *-e™\  -tibial  nerve
Branch.                which is  situated  on
its inner side  above, but crosses over the
artery as it descends, to occupy its fibular
side.  Where  it descends behind the in-
ternal malleolus, it has the  tendons  of the
tibialis  posticus and  flexor  communis in-
vested  in  their aponeurotic  sheath, be-
tween it and that prominence,  and on  its
posterior part, the  tendon of the  flexor
longus pollicis.
  Near  its origin,  the posterior tibial ar-
tery furnishes  several muscular branches
to the  popliteus, gastrocnemius, soleus,
tibialis  posticus,  and flexor communis di-
gitorum.   But the  only one deserving a
particular description  is the following:—
 
382
ARTERIES.  (Special Anat.)
  a. R. peronaus. The peroneal, or fibu-
lar artery  (Fig. 24. g.),  which varies
much  in  size, generally arises from the
outer part of the posterior tibial  artery,
about  an inch, or an inch  and  a  half,
below  the separation of that vesselfrom
the popliteal,  and passes  thence in  an
oblique direction downwards  and slightly
outwards, towards the inferior part of the
fibula.   In  its course,  the artery passes
first through a portion of the fibres of the
tibialis posticus,  to reach  the inner side
of the  fibula.   It then courses along that
bone, in front of the interosseous ligament,
and is overlapped by the flexor longus pol-
licis.   About two inches above the exter-
nal malleolus  it divides into two terminal
branches, one of which  is posterior,—the
other  anterior.  In the  upper portion  of
the leg,  it  is covered by  the gastrocne-
mius and soleus muscles; lower down, by
the long flexor of the great toe,  and the
deep-seated aponeurosis which passes over
that muscle and the tibialis posticus. From
its origin to the point at which  it divides
above the ankle, the peroneal artery mere-
ly furnishes small ramuli  to the  tibialis
posticus, peronaeus longus  and brevis, the
gastrocnemius  and soleus, the long flexor
of the  great toe, and the fibula.   It  then
terminates in the following branches:
  a.  Ramulus peronaus anticus.  The
anterior  peroneal artery  is  generally
small, and is sometimes  wanting.  It per-
forates  the interosseous ligament  about
two inches above the malleolus, to reach
the  anterior  part of  the leg,  whence
it ranges obliquely downwards and out-
wards  beneath the peronaeus tertius mus-
cle.  In the vicinity of  the anterior face
of the ankle joint, it divides into numerous
ramusculi, which are distributed  to the
articulation, the dorsum  of the tarsus, and
the outer portion of the foot.  Some of its
ramifications turn inwards  to anastomose
with  the tarsal branch of the anterior
tibial artery.  Others  incline  outwards,
below the external malleolus, and  anasto-
mose with the  posterior peroneal ramulus,
and the external plantar artery.
   When  the anterior tibial artery is ab-
sent or preternaturally small, this branch
supplies its place; and in such cases it is
very large.
  (3. R. peronaus posterior.   The poste-
rior peroneal artery (Fig. 24. i.) preserves
the direction of the main artery.   It de-
scends behind the external malleolus, pos-
terior to the tendons  of  the peronaei mus-
cles, and where it reposes upon the exter-
nal surface  of the os calcis,  divides into
numerous ramusculi,  some  of which pass
into the substance of that bone; others
pass backwards to anastomose with the
branches  of the posterior  tibial; while
many of them are spread  out upon the
dorsum of  the  tarsus  and the  abductor
muscle of the little toe,—the first to an-
astomose with the  tarsal and anterior pe-
roneal arteries, the others with the exter-
nal plantar.
  The posterior tibial artery, after it gives
origin to the peroneal ramus, does not fur-
nish any  important branches untd it is
about to turn into the sole of the foot (Fig.
25. a.), where, as previously remarked, it
terminates by dividing  into the internal
and external plantar arteries.  In its de-
scent down the leg, it  merely furnishes
small ramuli to the adjacent muscles, and
near the middle of the member, one which
penetrates the posterior face  of  the tibia
in an oblique direction from above down-
wards.  This is the r.  nutritius tibia,
which enters the medullary canal of that
bone, and is expended upon the  marrow.
Near the internal malleolus,  it also sends
small  branches forwards to  anastomose
with the anterior peroneal ramulus,—and
others which  go backwards,  towards the
tuberosity  of the  calcis, to anastomose
with the posterior branch of the  peroneal
artery.
   b. R. plantaris  internus.   The inter-
nal plantar artery (Fig. 25. d.)  passes
       Fig. 25.       directly forwards be-
                   neath the tibial mar-
                   gin  of the  foot  a«
                   far  as  the first pha-
                   lanx  of   the  great
                   toe.  It  glides first be-
                   neath the internal an-
                   nular ligament of the
                   tarsus, and above the
                   posterior  part of the
                   abductor pollicis;—af-
                   terwards   along  the
                   lower surface of the
                   short flexor   of  the
                   great toe, parallel with
                   the tendon of the long
                   flexor,  and  beneath
          nbiai Artery. the   first  metatarsal
b,  Wh  to O.  Calcis.  c bone.  At its  Origin,
External Plantar,  d, Internal        ,,   ,    /° •
Plantar,  e, Commencement a  Small   branch IS
D*ig»eaiF1A^toitrehv/A^u> reflected   backwards
mo,i*-               along the surface of
the calcis, towards the  tuberosity of that
bone;  and as it advances, it gives ramus-
culi to the abductor and  flexor muscles of
the great toe,—also to  the  integuments
of the  inner  part  of the  foot  some of
these winding round the  inner part of the
tarsal and metatarsal bones to anastomose
 
ARTERIES.  (Special Anat.)
383
 with  the  arteries on the dorsum; and at
 its termination,  it  divides  into  several
 small ramuli, which are expended  upon
 the integuments of the  great  toe.
   c.  R. plantaris externus.  The exter-
 nal plantar  artery  (Fig. 25. c.)  is much
 larger than  the  preceding,  and  may be
 regarded  as  the continuation of the pos-
 terior  tibial  artery.   From  the inner
 side  of the  calcis,  it proceeds obliquely
 forwards  and outwards,  towards  the base
 of the fifth metatarsal bone; it then passes
 forwards  a  small  distance, and finally
 sweeps across the sole  of the foot (Fig.
 25. e.)  to the interval which separates the
 first  from the  second  metatarsal bone,
 where  it anastomoses with the communi-
 cating  ramus of the anterior tibial artery,
 thus completing the plantar arch,  the con-
 vexity of which is directed forwards and
 outwards,—the concavity backwards and
 inwards.  In pursuing this course, the ex-
 ternal plantar artery passes first between
 the os calcis  and the head of the abductor
 pollicis; then between the short flexor of
 the toes and the accessory muscle.  Near
 the outer part of the foot, it is quite su-
 perficial, and reposes between the abduc-
 tor and short flexor of the  little toe; but
 where it sweeps across beneath the poste-
 rior part of the metatarsal bones,  to reach
 its termination, it runs between the inter-
 ossii muscles and the tendons of the com-
 mon flexors.
   In  the  first part of its course, and be-
 fore it begins to form the arch,  the exter-
 nal plantar artery furnishes numerous ra-
 musculi to the muscles  and other struc-
 tures in the sole of the  foot, which anas-
 tomose  with  the internal plantar artery.
 In the vicinity of the fifth metatarsal bone,
 several  pass upwards to supply the integu-
 ments,  and anastomose with the peroneal
 and tarsal arteries.   From the arch itself,
 ramuli  are  distributed  backwards,  up-
 wards, and forwards.
   o. The  posterior branches proceed di-
 rectly backwards and are expended upon
 the deep-seated  parts in the sole of the
 foot some of them supplying the articula-
 tions  of the tarsal bones.
   i3.  R. perforantes.  The  perforating
 arteries are three small  branches, which
 arise  from the upper portion  of the plan-
 tar arch.   They plunge into  the inter-
 ossii   muscles,  between  the metatarsal
 bones, and after  supplying them,  pass to
 the dorsum of the instep, where they an-
astomose with the branches of the  anterior
tibial artery.
  v.  R. digitales.  The  digital  arteries
(f^g. 25. f.) are the largest branches fur-
nished by the arch, from the convexity of
which they take their origin.   There are
generally four, corresponding  to the four
last  toes, which  are designated  numeri-
cally, counting from without inwards.
  The first arises opposite the fifth meta-
tarsal  bone, and  advances obliquely for-
wards and outwards to the fibular side of
the little toe, upon which it is expended,
after giving branches to the  flexor brevis
and  adductor minimi digiti.  The second
advances along the fourth metatarsal space
to the vicinity of the first phalanges, where
it divides into two branches, one of which
supplies the tibial side of th.e little toe,—
the other the fibular side of the toe next
to it  The third and the fourth  are dis-
posed in  the same manner, as regards the
third and second  interosseous  spaces, and
the  corresponding toes,  each of them di-
viding into two collateral branches, which
are distributed upon opposite sides of the
toes they are destined to  supply, in the
manner already described.  The great toe
alone, and the tibial side  of the second toe,
are  supplied from the  anterior tibial  ar-
tery : all the rest derive  their vessels from
the plantar arch.,
  Three of the  digital  arteries, just be-
fore dividing,  send  a  small  branch up-
wards through the anterior extremity of
the  corresponding interossii  muscles,  to
inosculate on the dorsum of the foot, with
the  metatarsal branch of the anterior ti-
bial  artery.   They are denominated ante-
rior perforating arteries,  to  distinguish
them from the posterior, which  are fur-
nished by the arch.   The collateral arte-
ries  of the toes  advance forwards to the
tip of each of those members, forming fre-
quent  anastomoses with each other, and
at their  termination, the  branches from
opposite  sides  inosculate to form  an arch
(Fig. 25. g.)  in  the  same manner as  in
the fingers.
   Varieties of the anterior and posterior
tibial, and peroneal arteries:
  The anterior tibial artery is occasion-
ally  much  smaller than natural,  or alto-
gether absent in the lower part of the leg.
In such cases, its place  is  generally sup-
plied by the anterior peroneal ramulus,
which perforates the interosseous liga-
ment,  and  forms  the  dorsalis pedis. (Tie-
demann.)  In some instances, when this
artery is wanting, branches are sent from
the  posterior tibial artery to compensate
for the deficiency.  Pelletan reports the
case of a man, whose anterior tibial ar-
tery lay so superficial, that its pulsations
excited at first a suspicion of the existence
of aneurism.   The same anomaly  existed 
384                         ARTERIES.  (Pathology.)
in one of the children of the individual.
(Clinique Chirurg. I.  101.)
   Peroneal artery.  This  artery  varies
much in size and distribution.  It is some-
times wanting,  its place  being supplied
by branches  from the  posterior  tibial.
When the anterior tibial artery is smaller
than uswal,  the peroneal is generally in-
creased in size,  to  compensate for the de-
ficiency.   In  such cases  it occasionally
supplies the dorsalis pedis. (Tiedemann.)
In an example observed by Otto, it took
its origin at the usual point;  but a little
above the ankle, turned inwards, and be-
came united with  the  posterior  tibial ar-
tery.  (Seltene Beobacht.   H.  63.)   In a
case  figured by Green, the peroneal ar-
tery  communicated above the heel, with
the posterior tibial, by a transverse branch,
and  afterwards descended  to the sole of
the foot to furnish the  internal and  exter-
nal plantar arteries.
   The posterior tibial artery seldom va-
ries much in its distribution.   A case has
been  delineated  by Green, in  which  it
was  double,—the  two  vessels descending
parallel with each  other.   When this ar-
tery  is wanting, the peroneal is increased
in size, and supplies its  place.  (Burns,
Barclay,  279.)   In such cases,  it  is re-
marked by Burns,  that the internal plan-
tar artery is often absent.
   The varieties of the  plantar  and digital
arteries are so numerous, that they cannot
be described.  Their anomalies are fortu-
nately of but little importance.
  Bibliography.—Wreden, (J. E.)   Arteriolo-
gisch. Tabellen.  Fol.  Hanover, 1721.
  Haller, (Albert Von.)  Icones Anat.   Fasc.
ii. iii. iv. v. vi. vii.  Gotting. 1745-1756.
  Chirol.  Tableau de toutes les arteres du corps
humain. Fol.  Paris, 1762.
  Murray, (Adolph.)  Discriplio arteriarum
corporis humani in tabulas redacta.   4to.   Upsal,
1780-1783.—Ibid.  A  description  of the arteries
of the human body, reduced to tables. Translated
from  the original, by Archibald Scott.  8vo.
Edinburgh, 1800; and Philadelphia, 1810.
  Posewitz, (Joh. Fr. S.)  Physiologie der Puis-
adern des  Menschlichen Korpers.  Nebst einer
vorausgeschichten Beschreibung des Herzens und
einer tabellarischen Uebersicht der beiden arteri-
osen Systeme.  8vo. Erst Theil.  Leipzig, 1795.
  Scarpa, (Ant.)  SulV aneurisma,  rifessioni et
osservazioni anatomiche chirurgiche.  Fol.  Pavia,
1804.   In English, by Wishart.
  Rosenmuller, (J.  C.)    Chirurgische-Anato-
mische Abbildungen fur Aerzte und Wundarzte.
3 Theile.  Fol.  Wiemer, 1805-1812.
  Barclay, (John.) A description of the arteries
of the human body.   12mo.   Edinburgh, 1812.
  Bell, (Charles.)   Engravings of the arteries
of the human body.  Svo. London, 1811.  Fourth
edit 1824.
  Munz, (Martin.) Gefasslehre, oder Lehre von
dem Herzen den Arterien, &c., mit Abbildungen.
1 vol. 8vo.  Plates in large Fol. Landshut, 1821.
  Tiedemann, (Fred.)  Tabula arteriarum cor-
poris humani.  Grand Fol.  Carlsruhe, 1822.
  From this splendid work, die wood cuts illus-
trating the above article have been drawn.
  Harrison, (Robt.)  Surgical anatomy of (he
arteries.  2 vols. 12mo.  Dublin, 1824.
  Turner.  A practical treatise on the  arterial
system.  8vo.  London,  1825.
  Dermott, (G. D.)   Illustrations of the arteries,
connected with aneurism  and surgical operations.
Fol.  London,  1825.—Ibid. A concise description
of the locality and distribution of the arteries of
the human body.  Plates.  London, 1827.
  Bierkowskie, (L.  J.)   Anatomische-Chirur-
giscke Abbildungen, &c.  Fol.   Berlin, 1826.
  Langenbeck, (C. J. M.)   Icones  anatomica.
Angiologae Fasc. i. Tab. aen 11.  Fol.  Gotting.
1827.
  Bujalsky, (Eliae.)   Tab. anatomico-chirurgi-
ca  operationes  ligandarum arteriarum majorum
exponentes.   Elephant Fol.   St. Petereburgh.
  Manec.   Traiti thiorique  el pratique des liga-
tures des artlres.  Fol.  Paris, 1828.
  Froreip,  (R.)   Chirurgische Anatomie  der
LigaturesleUen am  Menschen K'urper.   Mit 18
kpft.  Fol.   Weimer, 1830.
  Green, (P. H.)  On the varieties in the arterial
system.  Dublin, 1830.
  Smith, (N. R.)  Surgical anatomy of the arte-
ries ; with plates. 4to. 2d edit  Baltimore, 1835.
  Hopkinson.  Engravings of the arteries. 8vo.
Philada. 1833.
  See also the  various Treatises on Anatomy.

   Art. III.  Pathology  of the Arteries.
The tissues  composing  the arteries are
not exempt  from  the pathological  states
incidental to other parts of the organiza-
tion.  Differing as they do in their phy-
sical and vital properties, the modifications
of disease which are peculiar to each of
the tunics of these  vessels, are  so com-
pletely lost, in  consequence of their inti-
mate union with each other, and  the cor-
responding association of their vital acts,
that with a few exceptions, it is impossible
to discriminate between them.  We shall
be  compelled, therefore, in  making an ex-
position of their various pathological states,
to consider them as they affect all the tis-
sues collectively, and without any special
reference  to  each individual tunic  as un-
connected with the rest.   Considered in
this point of view, the pathology of the
arteries may be reduced to the following
heads : 1.  Modifications of relation :  2.
Alterations of texture:  3.  Alterations of
form and  volume:  4. Solutions of conti-
nuity : 5. Lesions of innervation:  6. Ento-
zoa infesting  their cavity.
  The first division  of the subject com-
prising the varieties in the  origin and dis-
tribution of the arteries, has been already
considered in connexion with  the special
anatomy  of  these  vessels.  It  only  re-
mains, therefore, to treat of the others in
the  order  in  which they have been enu-
merated,  premising that  many of the de- 
                         ARTERIES.  (

tails pertaining to some of the  subjects,
have been already discussed in  the  arti-
cles Aneurism and Aorta.
  § 1.  Inflammation of the arteries.  (Ar-
teritis, Arteriitis, Angioitis.)  Inflamma-
tion of the arteries may be either acute or
chronic:  it may be  confined to a limited
portion of one of the vessels: it may im-
plicate several isolated portions of one or
more  of them,  or  it  may be diffused
through the whole arterial system.  In its
various modifications and consequences, it
may be  characterized  by increased  red-
ness of the tissues of the vessel, soften-
ing,  induration,  effusion of  coagulable
lymph and the formation of pseudo-mem-
branes, suppuration, ulceration, mortifica-
tion, various transformations of tissue, in-
crease or diminution  of the calibre of the
vessel, obstruction and complete oblitera-
tion.   We shall first consider the anato-
mical characters of each of the  forms of
inflammation, and afterwards treat of its
causes, symptoms, diagnosis,  and treat-
ment
   a. Acute inflammation of the arteries.
Acute idiopathic  inflammation of the ar-
teries  seems to have been first noticed by
Aretes.  After detading the symptoms
which characterize  inflammation of the
vena cava, he goes on to remark, " quibus-
dam et arteria secundum dorsum inflam-
matur; quod pulsatio in alteris praecordiis
manifestat" &c.  (Aretai Cappadocis de
caus. et sig. acut. morb.  Lib. II. cap. viii.)
Notwithstanding it was afterwards noticed
incidentally  by  Boerhaave,  Morgagni,
and various  other writers,  it  never at-
tracted much consideration,  until J. P.
Frank pointed out its importance.  He,
indeed, supposed that he  had been the
first to discover it, and remarks, that " in
violent inflammatory fevers, attended  with
extreme  agitation of the  heart and  arte-
ries, I first discovered a deep inflammatory
redness of these vessels, and  also of the
whole  venous system." (Epit. de curand.
Horn. morb.  Lib. I. § 118.)  Certain  it is,
that with the  exception  of traumatic in-
flammation of  the arteries arising  from
the application of ligatures and other in-
juries, the disease had  never been pro-
perly investigated previous to his time,
and to the attention which the above re-
mark had the tendency to direct to it are
we indebted for the important information
which  has  been subsequently developed
by those  who have made  it a subject of
inquiry.  We shall  examine  each of its
anatomical characters separately.
  Redness.   Acute  inflammation  of the
arteries  is generally attended with more
  vol. ii.         33
Inflammation.)                       385

or less  redness of the lining membrane,
which is  either confined to one or more
small points, or more extensively diffused.
The intensity, and the different shades of
this  redness, vary much, according to the
violence of the inflammation, the term of
its duration, the condition of the vessels,
and  other circumstances placed  beyond
our  cognizance.   It may assume all the
intermediate tints between a light pink,
and  a deep crimson, scarlet, brown  pur-
ple,  or  even blackish hue.  The deeper
shades of colour are more particularly ob-
servable in the lining membrane  of the
arteries in connexion with the  violent in-
flammation which follows the application
of a ligature (Gendrin.  Hist. Anat. des
inflammations. II. 9. Paris, 1826.); though
we have  recently found the lining mem-
brane of the aorta presenting an intense
reddish-brown  colour  to  some  extent,
which was associated with violent inflam-
mation  of that vessel, characterized  also
by  a flocculent  pseudo-membranous de-
posit upon its inner surface.
  This morbid coloration may occupy the
entire circumference of a portion of the
vessel,  or be  diffused  throughout  the
whole internal surface of the arterial and
venous  systems, as happened in  some of
the  instances  observed  by Frank.  But
when the disease affects the larger arte-
ries, it often  presents itself in form of
small patches, or  streaks, of variable ex-
tent and  configuration, which  either ter-
minate  abruptly,  or  lose themselves in-
sensibly in the adjacent portion  of the
membrane.  They frequently have other
spots of a  healthy colour interposed be-
tween them, the whole  arrangement ex-
hibiting a variegated appearance, not un-
like the  figures on  a  piece of marbled
paper.
   Laennec first questioned the value of
simple redness as an evidence of  inflam-
mation  of the lining membrane of the ar-
teries.  He concluded from numerous ob-
servations and experiments, that it should,
in a majority of instances at least, be as-
cribed to a simple tinting of the tunics of
the  vessels, occasioned either by the  con-
tact of coagulated blood after death, or the
imbibition, by the tissues, of the colouring
matter* of that fluid.  The same opinion
was advocated by Hodgson, and although
at first it encountered some opposition, it
has since  received the general sanction
of pathologists, notwithstanding they all
acknowledge that acute inflammation of
the  arteries is generally attended  with
 more or less redness.  In treating of in-
 flammation of tlie aorta, we have already 
386
ARTERIES.  (Acute Inflammation.)
considered the arguments upon which this
opinion is founded, and deem it sufficient
on the present occasion to remark, that no
degree of redness  of the arterial tunics
can be with certainty  pronounced inflam-
matory, unless it be associated with some
appreciable alteration  of their texture, or
a deposition of coagulable lymph or pus
upon their surface, or in the substance of
the coats of the artery.
  The true inflammatory redness is, be-
sides, often  associated with more or  less
injection of the  vasa vasorum, and is not
limited to the lining membrane, but occa-
sionally extends to the  fibrous and cellular
tunics.   This  injection cannot be distin-
guished  in the lining  membrane, but is
very conspicuous between that tunic  and
the fibrous coat.  In the latter it is never
very conspicuous, but  if all the coats of
the artery be  affected, the cellular tunic
will often be found intensely injected, the
vasa vasorum forming a delicate plexus
of minute  vessels  which traverse  its
meshes in every direction.  This charac-
ter of inflammation, however, is not al-
ways present.  Bouillaud speaks of it as
being rare,  and  although it has been de-
signated by  other pathologists as of com-
mon occurrence, it should be remarked,
that even when present, it does not posi-
tively indicate the existence of inflamma-
tion,  since it  may be  produced by many
other causes.  Whatever occasions much
obstacle  to the free passage  of the blood
through  the heart and lungs during the
agonies  of death,  or  for  some time  pre-
vious to that event, is apt to  give rise to
preternatural  injection of the entire ca-
pillary system,  and   the vasa  vasorum
among the rest.  Hence, persons who have
died from hanging or drowning, and those
destroyed by serious diseases of the heart
and lungs, often present the  condition in
question in a conspicuous degree.  The
abrupt termination of the  spots or lines of
redness in the surrounding parts, has been
mentioned as one  of the characters by
which simple  tinting  of the  coats of the
vessel from imbibition  may be distinguish-
ed from the red colour of inflammation,
which, it has been said, loses  itself by in-
sensible  shades.   This opinion, which we
were disposed to consider valid when the
article Aorta was penned, we have since
ascertained  is  not founded in  fact  In the
case of acute arteritis alluded  to  above,
the  intense redness of the lining mem-
brane  of the aorta exhibited the abrupt
termination, the stripes, spots,  geometrical
figures, &c, thought  to be characteristic
of simple tinting; yet it was lined for a
considerable  distance  by a  soft pseudo-
membranous deposit of a gelatinous con-
sistence, and besides presented other un-
equivocal evidences of inflammation.
  Modifications of texture.   Far more
positive characters of inflammation of the
arteries are furnished by the alterations
of texture  which these vessels undergo,
and the products secreted from  them un-
der the influence of this process.  Shortly
after the commencement of the disease,
the lining membrane loses  its natural
smooth polished aspect:  it  becomes tu-
mid, soft, irregular, uneven or villous, like
the serous  membranes of the splanchnic
cavities when similarly affected; and the
delicate substratum of cellular tissue which
unites  it to the fibrous coat, also becomes
soft  and infiltrated, so as  to allow  the
lining  membrane to be  easily detached,
and sometimes in considerable  flakes or
shreds.  The  fibrous coat participates in
the same change: it is thickened; loses
its  elasticity; becomes soft, friable, and
more humid than natural; acquires a red-
dish-yellow colour,  and is converted into
a kind of cellular or filamentous tissue, so
destitute of consistence, that it yields un-
der the slightest force.  The cellular coat
undergoes  similar  changes:  it becomes
tumid  and injected, and although still re-
taining more of its cohesiveness than the
other  tunics,  it is rendered much more
fragile and less elastic than  natural.
  Albuminous and pseudo-membranous
deposits.  With these alterations  of tex-
ture, there are generally developed con-
siderable modifications of secretion. Short-
ly after the inflammation commences, an
albuminous coagulable fluid is poured out
in considerable abundance upon the inner
surface of the affected vessel,  where it
sometimes  becomes consolidated  into a
soft viscid  pellicle,  which adheres to the
lining  membrane, and by progressive ac-
cumulation sometimes forms a continuous
flocculent pseudo-membrane of some ex-
tent, so intimately united to the internal
tunic that  it cannot be washed away by
the stream of blood.   These albuminous
concretions are, however, seldom thus ex-
tensive.  The  plastic  deposit  is  oftener
disseminated in small spots, presenting a
flocculent or tomentose appearance.   Co-
existent with this  change, or even ante-
rior to its occurrence, a kind of serous in-
filtration takes place in the  areola of the
arterial tissues, by which they are rarefied
as it were, and in proportion as their co-
hesiveness  is  impaired,  the presence of
this fluid tends to augment their softness,
and impart to them a preternatural degree 
ARTERIES. (Acute Inflammation.)
387
of humidity. This serous effusion is gene-
rally  mixed  with more  or  less  plastic
lymph,  and after  the  inflammation  has
continued some time, the latter material
preponderates, and occasions eventually a
slight solidification and thickening of the
coats of the artery, especially when the
disease passes into the chronic form.
   These  are the  phenomena  observed
when the inflammation seizes upon the
larger arteries, as  the aorta, pulmonary
artery, &c.  It may happen, however, not-
withstanding coagulable lymph is  poured
out abundantly by the lining membrane of
the inflamed vessel, that no albuminous con-
cretion or pseudo-membrane  will be  dis-
covered adhering to the inner surface of
the artery.   The torrent of blood sweep-
ing along the  inflamed membrane often
carries with it  the  morbid secretion as
soon  as it is poured out, thus preventing
it from becoming concrete, and  leaving
no trace behind, to indicate the nature of
the process going on in the inflamed  part.
This  is the  reason  why albuminous or
pseudo-membranous  deposits  are  so  sel-
dom  observed in tlie large arteries  as a
consequence of acute  inflammation,   not-
withstanding there is  reason to believe
these vessels  are  oftener affected  with
that  disease,  than  some  circumstances
seem to indicate.   Nevertheless, the  in-
 stances in which these adventitious forma-
 tions have been observed, are sufficiently
 numerous to establish the fact of their de-
pendence on inflammation.  In the aorta
of an individual who died recently of acute
arteritis and carditis  supervening  upon
the application  of a ligature to the  bra-
chial  artery  after amputation  of the  arm,
we found the  lining  membrane of  that
vessel exhibiting an intense Modena-red
colour, and coated over to a considerable
extent with  a soft viscid flocculent layer
of plastic lymph, which could be  readily
scraped from its surface.  Examples of an
analogous character have been reported
by Haller (Opusc. Path. Obs. 47. p. 127.),
J. P. Frank (Epit. de curand. horn, morb.),
Spangenberg (Horne's Archiv. fur Med.
Erfahr. V. 1814.), Weldon (Coxe's Med.
Museum.  IV. 60.),  Hodgson (Traite des
maladies des arteres, &c. I.  6.),  Farre
(Ibid. 5.), Kennedy  (Med. Chirurg. Re-
view.  II. 61.), Bayle (Bibliotheque Mid.
1821.), B.  Coates (N. A. Med. and Surg.
Journal. VIII.  288.), Bertin and Bouil-
laud (Traite des maladies du cceur. p. 6.),
Gendrin (Hist. Anat. des inflammat.  II.
16.), Hope (Cyclopadia of Practical Med.
Art. Arteritis),  Samuel Jackson (Amer.
Journ. of Med.  Sciences.  XV. 296.), and
others, whose authority it would be need-
less to quote.
  When inflammation attacks arteries of
smaller size, other phenomena are observ-
ed which  do not take place in vessels of
large calibre.  Under such circumstances,
besides the  changes already described as
taking place in the coats of the  vessel,
the blood itself experiences very  impor-
tant  alterations, and  that  portion of  it
which circulates through the inflamed ar-
tery,  is coagulated into a solid mass, which
closes the calibre of the vessel as high as
its  nearest  collateral branch.  After the
colouring matter of the coagulum is re-
moved, a solid fibrinous  plug remains,
which either adheres  loosely  with  the
lining membrane, or is attached to it by
the plastic  lymph poured out by that tis-
sue.  (See  Obliteration and Wounds of
Arteries.) This constitutes the proper ad-
hesive inflammation of the arteries. It is
the process  by which they are  obliterated
when a  ligature is applied to them,  and
this obliteration or  adhesion will  always
take  place with greater promptness when
the vessel is small, or has its walls closely
compressed, so  as to be brought in appo-
sition. In the same way, also, arteries are
obliterated which terminate in a gangren-
ous  part, when they traverse  any of the
tissues of the body affected by a disorgan-
izing disease, and when they are divided
or otherwise wounded; so that while this
species of inflammation is often a source
of serious mischief,  it likewise frequently
exercises a  most salutary agency.
   It  has been questioned by some patholo-
gists, whether the formation of this fibrin-
ous plug filling up  the calibre of the ar-
tery, takes  precedence of the injection  of
the  vasa vasorum, the  consequent devel-
opment of preternatural redness of the tu-
nics  of the  vessel,  and the deposit of co-
agulable lymph; or  whether it is not con-
secutive to those changes.  The results ob-
tained from numerous  experiments seem
favourable to the first conclusion.   It has
been ascertained, that when an artery  of
small size  is contused or  violently  irri-
tated, one of the first changes observed is
the  coagulation of the blood within  it
which completely  obstructs  its  cavity,
while the phenomena characteristic of in-
flammation  in the  arterial  tunics, only
show themselves at a later period.  This
is precisely  what takes place after the ap-
plication of ligatures to arteries—in lace-
rated wounds tearing them across, and  in
violent contusions  affecting their struc-
tures. The two crural arteries of a dog
were exposed and  irritated with cantha- 
388
ARTERIES.  (Acute Inflammation.)
rides.   On examining them two days af-
terward, they were found inflamed upon
their external  surface, and filled with a
solid mass of coagulated blood.  (Sasse.
Dissert', de  vasor.  sanguif.  inflammat.
Halle, 1797.)
   These considerations induced Cruveil-
hier and others to conclude, that the ob-
struction of the vessel by the coagulation
of the blood within, is always one  of the
first consequences of inflammation  of the
arteries.  The same opinion  was at one
time espoused by Berard (Arch. Gen. de
Med. X.), but subsequent observations in-
duced him to modify his views.   The ne-
cessary inference from this doctrine is,
that tlie course of the blood  through an
inflamed artery must always be arrested.
Finding, therefore, that there are cases in
which no such obstruction takes place, be-
cause  there  is no coagulum formed, he
was compelled to grant, that the inference
will not admit  of universal  application.
(Diet, de Med. IV. 105.)   It may be con-
cluded  from  an impartial examination of
the whole grounds of the discussion, that
when  inflammation is a consequence of
serious injuries,—when it succeeds the
application of a ligature to an artery, the
operation  of an  intense  irritant upon a
vessel,  &c,  the  sentiment of Cruveil-
hier is not without foundation.   But un-
der  other  circumstances,  especially in
those cases  in which the  morbid process
takes place spontaneously, it is contradict-
ed by general experience; the whole phe-
nomena observed in such instances, clear-
ly demonstrating, that when  obliteration
does take place, the primary cause of it is
a deposition of plastic lymph upon the in-
ternal surface of the vessel.
  Purulent secretion within the  arteries.
Purulent matter is  seldom found in a free
state within  the  arteries, although it is
rendered probable both by reason and an-
alogy, that it is  often thrown out by the
lining membrane  of  these vessels  when
affected with violent  inflammation.   The
same cause which tends  to prevent the
coagulable  lymph which  is deposited by
that tissue from accumulating, also sweeps
away any purulent matter which may be
poured  out under similar  circumstances,
and it is owing to this cause, that it is so
seldom  met with  as a character of arte-
ritis.  It is more frequently encountered
either collected into small pustules  or ab-
scesses  beneath the lining membrane, or
in a state of infiltration in the coats  of the
arteries and the adjacent  structures.  In
the article  Aorta, we have detailed sev-
eral cases  on the authority  of Monro,
Welch, Storck, Weitericht,  Andral,
and  Loestein, in which that vessel was
affected  with  suppuration  and abscess.
Morgagni reports  a case in which the
lining membrane of nearly the whole ar-
terial system presented small prominences
or pustules,  the largest of which,  when
cut  poured out a soft pultaceous matter.
(Epist. xxii.  No. 28.)  In an instance or>
served by Andral,  in which several lob-
ules of the lungs seemed to be infiltrated
with pus, he  ascertained that the appear-
ance was  owing to the ramifications of
the  pulmonary artery  being filled with
that fluid.  (Precis d'Anat. Path. II. 379.)
Bouillaud, in examining an aorta which
was  studded  over upon its  inner surface
with numerous points of ossification, dis-
covered  several small  purulent deposits,
the fluid from which presented all the pro-
perties of genuine pus.  (Diet, de Med. et
de Chirurg.  Prat.  III. 408.) In a female
who  died  of laborious   miscarriage, the
spermatic  arteries  and  veins were  found
red and inflamed, and filled with purulent
matter;  and  Lobstein found the arteries
which ramified in the vicinity of a vomica
of the lungs, containing pus. (Traite d'-
Anat. Path.  II. 544.)  Guthrie remarks,
that  purulent matter is  often found in the
umbilical artery of  infants, and, with the
inflammation which gives rise to it is a
frequent cause of death  (Diseases and in-
juries of the arteries,  p. 13.): and in  a
case of extensive and protracted suppura-
tion  of the hand and fore-arm, Sprengel
found the internal membrane of the radial
and  ulnar  arteries  thickened, eroded, co-
vered with a false  membrane, and  those
vessels filled  with pus,  from the wrist to
the middle of the fore-arm. (Rust's Ma-
gazin der Gesammte   Heilkunde,  and
Journ. Complimentaire, VIII. 87.)
  The  purulent secretion  is sometimes
prevented  from being washed away, by
the presence  of a fibrinous mass filling up
the calibre of the vessel.  An example of
this  kind has been reported by Graves
and Stokes. (Dublin Hosp. Reports.) The
puriforni fluid occupied the space between
the fibrinous concretion and the inner sur-
face  of the  vessel.  In some  instances,
moreover, pus is found occupying the cen-
tre of a mass of this kind, so as to be per-
fectly  isolated  both from the fluid  blood
and the tissues of the artery. (See Blood.)
  If in addition to  these facts, the great
liability of any fluid secreted by the dis-
eased coats of the  arteries,  to be carried
along with tlie tide  of the circulation,
be considered, and if at the same time
we take into  account the comparatively 
ARTERIES. (Acute Inflammation.)
389
 limited attention which has been devoted
 to the examination of the arteries after
 death, it will appear highly probable, that
 the pathological state in question  occurs
 much oftener than might be inferred from
 the few examples  of it which have been
 reported.
   Ulceration of the arteries.  Ulceration
 seldom follows  acute inflammation  of the
 arteries, though a frequent consequence
 of the chronic form of the disease.  The
 ulcers vary much in their  size and gene-
 ral characters.   Sometimes as small as
 a pin's head, they are  often much larger,
 some of them being half an inch or more
 in diameter.  When most superficial, they
 consist of slight erosions, which impart to
 the surface of the  membrane a rough to-
 mentose  appearance.   Those which are
 more  profound,  destroy the lining  mem-
 brane of the vessel, and  have their bot-
 tom formed  by  the fibrous coat; and in
 some of them, this tunic is also destroyed.
 In such cases,  the cellular coat  either
 yields before the distending force of the
 blood, and is dilated, so as to form an an-
 eurismal sac, or it participates  in the ra-
 vages of the ulcerative  process, and  a
 complete perforation of tlie walls of the
 artery takes place.  (See Perforation, and
 Rupture of Arteries.)
   Ulcers of  the arteries  of considerable
 depth generally have well-defined borders,
 which are a little elevated, in consequence
 of the injection and thickening of the sub-
 jacent tissues.   Sometimes they are rag-
 ged and uneven, having small portions of
 the lining membrane detached  and float-
 ing loosely in the cavity of the vessel, and
 very  often,  small masses  of coagulated
 blood are found insinuated beneath the se-
 parated edge of the membrane, imparting
 to the  contour of the ulcer a dark ecchy-
 mosed appearance.  The bottom is  gene-
 rally rough and uneven, and is either co-
 vered by a layer of coagulated  blood, or
 a darkish-coloured pellicle of a fibrinous
 consistence.  They are but rarely  found
 smeared over with pus, inasmuch as that
 fluid is carried away by the current of the
 blood as soon as formed.  In one instance,
 nevertheless, a large ulcer situated behind
 one of the .semilunar valves of the  aorta,
 was covered with a considerable quantity
 of purulent matter.  (Hodgson, p. 12.) In
 the article Aorta, we have referred to an-
 other case reported by Meckel,  in which
 the whole extent of the thoracic and ab-
dominal aorta was occupied by numerous
ulcers, the surface  of which was coated
with pus. (Mem. de l'Acad. des Sc. de
Berlin. XH.  1756.)
                 33*
   There is sometimes but a single ulcer;
 but more frequently there are  several, of
 various  sizes  and  configuration,  either
 clustered together in a  single portion of
 the vessel,  or irregularly disseminated
 over  its internal surface.  Occasionally,
 indeed, nearly  the whole extent of an ar-
 tery has been found  ulcerated at different
 points, leaving  portions of the lining mem-
 brane in the intervals retaining a healthy
 character.   This was the condition of the
 vessel in the case reported by Meckel, to
 which reference has just been  made, and
 also in  another instance observed by An-
 dral, who found nearly  the whole  extent
 of the thoracic and  abdominal aorta stud-
 ded with numerous  superficial ulcers as
 large as a five-cent  piece.  Examples of
 ulceration  of the aorta and other arteries,
 unattended with perforation,  have been
 reported by numerous  authors, amongst
 whom the  following may be cited: Mor-
 gagni (Epist. VII. 9. XXIV. 16. XL. 24.),
 Haller (Opusc. Path. Obs. XXII.), The-
 den ( Unterricht fur unterwundarzte, &c.
 p. 232.), Sandifort (06s. Anat.  Path.
 Lib. I. cap. ii.  p. 53.), Recamier (Journ.
 de Med. Chir. et Pharm. XI. 30.),  Gen-
 drin (Hist. Anat. des Inflammat.  II. 42,
 73.),  Scarpa (On Aneurism), and Lob-
 stein (Compte rendu  a  la Faculle de
 Strasb.  p.  114. Nos. 433, 435, and 437.).
 Besides these, we shall have occasion, un-
 der another head, to  refer to examples of
 ulceration  of the arteries terminating in
 perforation.
  Ulceration originates differently  in dif-
 ferent cases. 1. It consists primarily of a
 simple destruction of tissue by ulcerative
 absorption,  arising from inflammation, and
 independently of any mechanical cause.
 This was probably the character of the ul-
 ceration in  the cases observed by Hodgson
and Andral ; and Morgagni, in his Four-
teenth Epistle, refers  to  several  exam-
ples, in  which ulceration of the aorta was
produced, where there was no ossification
of the coats of the artery to occasion such
an effect by the mechanical irritation ex-
cited  by the earthy  concretions.   2. Ul-
cers of  the arteries may follow the open-
ing or rupture of small abscesses or athe-
romatous pustules situated beneath  the
lining membrane.  Scarpa has particu-
 larly explained  the agency of this  cause
 in the production of aneurism.   3.  They
 may succeed the detachment  of osseous
or calcareous scales  deposited within the
arterial  tissues, the beds of which become
converted into ulcerated surfaces.   Laen-
 nec remarks, that the small excavations
 left by the  separation of  these  scales are 
390
ARTERIES.  (Acute Inflammation.)
filled by decomposed fibrine of the consist-
ence ofa friable paste, which is often mix-
ed with carbonate of lime.  He moreover
subjoins, that their borders are frequently
reddened to a small distance by the infil-
tration of blood, which should not be attri-
buted to chronic inflammation.  ( Traite de
I'Auscult. mediate. II. 610.)  This latter
inference is not altogether correct.   Such
ulcers are  often associated with traces of
inflammation  too  palpable to admit of a
doubt of its existence. 4. Ulceration may
extend from the parts surrounding  an ar-
tery, so as  to involve its tunics from with-
out inwards, and in some cases.completely
traverse them, occasioning a  formidable
or fatal hemorrhage.  Notwithstanding the
arteries are endowed with a kind of con-
servative power,  in virtue of which they
are  enabled to resist for a long time, ul-
ceration, gangrene, and other morbid pro-
cesses affecting the  adjacent parts, cases
not unfrequently occur, in which they are
ulcerated,  and even opened,  by diseases
proceeding from  these  sources.  Cruik-
shank witnessed  an instance, in which a
fatal hemorrhage  was induced by an ero-
sion of the femoral artery commencing in
a  neighbouring bubo. (History of the ab-
sorbent vessels.)   Similar cases have been
reported by Travers and Gibbs (London
Med. and  Phys.  Journ.  1827.), and Be-
rard (Diet, de Med. Art. Aine.). Joseph
Frank saw a fatal hemorrhage result from
an ulceration of the  epigastric artery, oc-
casioned by a venereal bubo (Prax. Med.
 Univ. Pracept.  II.  pars. ii.  303.);  and
profuse hemorrhage from the lungs, sto-
mach,  intestines, &c,  not unfrequently
proceeds  from  such  a lesion  of  one or
more of their vessels. Hodgson witnessed
a fatal hematemesis, which  originated in
an ulcer of the mucous membrane  of the
stomach, destroying the coats of the coro-
nary artery of that organ; a second case,
 in which death was induced by ulceration
of the splenic artery,  communicated  to
that vessel by a cancerous tumour situated
behind the  stomach;—and  a  third,  in
 which  the same result took place from
 the ulceration of a considerable branch of
 the pulmonary  artery, which communi-
 cated with a vomica of the lung. (Loc.
 Cit. p. 13.)
    Softening of the  arteries.    Arteria
 malacia.   Malacosis arteriarum.   It has
 been already remarked, that one  of the
 earliest effects  of inflammation of the ar-
 teries is,  to  produce considerable  soften-
 ing of their  tissues.  It will be proper to
 consider this pathological condition more
 in detail,  as the  question is still unsettled,
whether  it should be referred to inflam-
mation when  not associated with  other
palpable  characters of that process.
  Softening of the arteries is constantly
observed as a consequence of the applica-
tion of a ligature to these vessels; but its
characters  as  an idiopathic condition, su-
pervening  independently of any previous
mechanical lesion, have not been studied
with  sufficient accuracy,  to justify any
very  positive  or  satisfactory conclusions.
It is  characterized by a manifest diminu-
tion of the  cohesiveness of one or more of
the arterial tunics, most generally of the
internal and middle, but occasionally also
of the cellular; and this condition may
be limited to a small portion of a  single
vessel, or  be  more  extensively  diffused,
occupying a considerable part or the whole
of the arterial system.  Vessels thus af-
fected are  deprived of  their  elasticity;
they  are incapable  of  sustaining even
slight force, and are disposed either to be-
come dilated  uniformly to a considerable
extent or partially, so as to lay the founda-
tion  of  aneurism.  The  latter changes,
however,  seldom take  place,  when the
softening is confined  to  the lining mem-
brane, and are chiefly observed when the
whole of the arterial tissues are involved.
When the disease attacks the lining mem-
brane alone, it is rendered preternaturally
friable, is  reduced to a pulpy consistence
possessing but little cohesiveness, and can
be easily scraped from the fibrous coat It
generally  has the  appearance  of being
slightly  thickened, tumid, uneven,  and
spongy,  and is devoid of the density na-
tural to  it.   These  characters sometimes
exist unassociated with any apparent infil-
tration or increase of  humidity,  though
very often the softness is increased by the
admixture of more or less fluid. Lobstein
alludes to a form of softening of the lining
membrane somewhat different  from  this,
 which he says consists in a kind of spongy
 tumefaction, giving rise to vegetations of
 sufficient  magnitude to  close  the  vessel.
 This condition was observed in the inno-
 minata to  the extent of half an inch, and
 that  vessel was reduced to one-third its
 natural  capacity by the spongy arrange-
 ment of the tissue.  It was also discovered
 in the subclavian and carotid arteries of
 another individual, who during the last
 years of his life  had experienced  two or
 three transient attacks of syncope. These
 excrescences, though encroaching consi-
 derably upon the capacity of the vessel,
 were so soft  as to be depressed  by the
 stream of blood.  (Traite d'Anat. Path. II.
 569.; also, Archiv. Gen.  VIII. 600.) 
ARTERIES.  (Acute Inflammation.)                    391
  It is not unusual to find all the coats of
the arteries rendered so friable, that they
tear under the  slightest force, although
they exhibit  no tumefaction, thickening,
or infiltration of fluid.  They are affected
with a kind of dry softening, or in other
words, their  natural  cohesiveness  is di-
minished, without any other appreciable
change.   This condition  is chiefly  a con-
sequence of chronic inflammation,  or  of
changes  in  the  development  of  which
acute inflammation has  no participation.
Hence it is often observed in those arte-
ries which traverse  parts affected with
cancerous and other  degenerations.
   In other  cases,  the  softening  of  the
fibrous and cellular coats is associated with
a manifest infiltration of the parts, either
with blood, serum, pus, or some other fluid.
Under these  circumstances, with the di-
minution of cohesiveness, there is a mani-
fest increase  of humidity,  and all the af-
fected tissues are soft, tumid, and spongy.
This condition is often a consequence of
acute inflammation  of the arterial  tunics,
and is especially observed  in the vicinity
of ligatures, and  in those arteries which
are situated in the neighbourhood of parts
affected with- profuse suppuration.  Lob-
stein remarks, that he has  seen the coats
of the arteries converted  into a spongy
tissue, analogous to the corpus cavernosum
of the penis,  from which blood issued by
an  infinity of orifices when  the vessel was
divided.   This was  observed in  the arte-
ries of the extremities;  and a case is re-
ported in the Journal de Medecine, an. xi.
p. 41, in which the radial  artery presented
a tumour of this kind, affecting its coats
to the  extent  of two inches.   When di-
vided in the living subject  it bled freely;
and when examined after being extirpated,
it was found to consist of a spongy mass,
infiltrated with  blood.   (Traite d'Anat.
Path. II. 569.)
   We are not as yet in possession  of any
very certain  criteria, by which we can
distinguish the form  of  softening  which
is a consequence of inflammation, from
another modification of the same condition
of the tissues, which seems to arise solely
from defective or imperfect nutrition. (See
Softening.)   In either case,  the  conse-
quences  of the lesion  are  similar.  The
liabUity of ligatures to slough away, and
the proneness to secondary hemorrhage in
cases where the coats of the arteries are
softened,  are  well  known;  but besides
these accidents, the condition  in question
disposes  to ddatation, to the development
of aneurism, and even to rupture  or per-
foration of the artery and the  induction
of fatal hemorrhage.  (See Rupture, and
Perforation.)  It  has been  observed by
Hesse, that idiopathic softening of the ar-
teries  is very generally associated with a
similar condition of the walls of the heart,
and that in a majority of cases it is con-
fined to the lining membrane. ( Ueber die
Erweichung der Gewebe und organe des
mensch. Korpers.  1827.)   We have seen
it  existing in the aorta, associated with
acute carditis and pericarditis.
  Gangrene of the arteries  is scarcely
ever observed, except when it is propa-
gated  to  these  vessels  from  a mortified
condition  of the surrounding parts;  and
even then their conservative energies en-
able them to resist the disease for a length
of time.   Very often, in extensive morti-
fication of the extremities and other parts
of the body, the main artery retains its in-
tegrity of structure in the  midst of parts
which  are completely dead and reduced
to putrilage,  and the whole of the  soft
parts surrounding the vessel may slough
away,  dissecting it clean  on every side,
yet its coats exhibit no evidences ofa par-
ticipation in the gangrene.   The arteries,
nevertheless,  often  undergo  important
changes in gangrenous parts,  although
their  vitality  is  not  destroyed.   It  was
long since noticed by Petit, Quesnai, and
O'Halloran, that the arteries of gangren-
ous limbs do not bleed on amputation  be-
ing performed in the  vicinity of the dead
part.   This they discovered was owing to
the vessel being rendered  impervious by
a firm  fibrinous coagulum, which, while it
plugs up its calibre, adheres intimately to
its lining membrane. In one case observed
by  O'Halloran,  no  hemorrhage  took
place,  although the  incision was  made
four inches above the line of separation
between the dead and living parts.  The
simple  coagulation  of blood, Thomson
thinks, is not of itself sufficient, without
the concurrent agency of adhesive inflam-
mation; and he affirms, that in several
cases which he examined where no bleed-
ing occurred on the  division of the  ves-
sels, no such coagulum existed. (Lectures
on Inflammation, p. 437.)  We have  sev-
eral times inspected the arteries of mor-
tified limbs,  and have almost  invariably
discovered considerable thickening of their
tunics, together with  small masses  either
of fibrinous concretion,  or  of albuminous
deposit, existing within. In nearly all cases,
they have been found  partially or com-
pletely obstructed, and this condition gene-
rally extends as high  as the origin of the
nearest collateral vessel above the line of
separation of the dead from the living parts. 
392
ARTERIES.  (Chronic Inflammation.)
  b. Chronic inflammation of the arte-
ries.  Arteritis chronicus.  Chronic  in-
flammation  of the  arteries is  probably a
disease  of frequent occurrence,—at least
the lesions  of their  tissues which have
been  generally attributed to this cause,
are perhaps as often met with as altera-
tions  of structure of the  other  organs.
How  far they  can  be  with justice  all
ascribed to inflammation is still a question
with pathologists, and we are  not as  yet
in possession  of sufficient  data to offer a
satisfactory  solution of the problem.   In
order, therefore, to group  all the altera-
tions of texture to which these vessels  are
liable under one head, we shall proceed to
describe them under the present section—
pursuing, in this respect, the same order
we adopted in treating of inflammation
of the aorta.
   Redness,  which  has been  spoken of as
a character  of acute  inflammation of  the
arteries, seldom exists in the chronic form
of the disease. The  lining membrane, on
the contrary, exhibits  a dull  yellow, or
grayish-brown colour, and often presents
a variegated or mottled appearance, owing
to the diversity of tints possessed by the
several  textural alterations  existing in its
tunics.   In  some  instances, nevertheless,
especially where the coats of the vessel
are studded over with calcareous scales or
points, the portion of the lining membrane
corresponding to the  contour of these  de-
posits,  presents a  dark  red, ecchymosed
appearance.  Where cracks and fissures
exist in the  membrane, this  redness is
sometimes  owing  to a small quantity of
blood becoming insinuated beneath it,  and
affords no evidence of inflammation.  But
in other cases, it is occasionally associated
with  manifest injection of the vasa vaso-
rum, and is indicative of preternatural ir-
ritation  of  those vessels, either superven-
ing as  a consequence of the mechanical
influence of the calcareous deposits, or ex-
isting independently of them, and consist-
ing in a degree of inflammation owing its
origin to some other  cause.
   Hypertrophy with induration (Arteria
sclerosis) of the tunics of the arteries  is a
very frequent consequence of  chronic in-
flammation.  Hodgson remarks,  that the
lining membrane is sometimes thickened,
and converted into a structure similar in
character to  the  peritoneal envelope of
an old hernia.  If, observes he, the tunics
be separated, it will be found that the dis-
ease  is  confined to the inner coat, which,
deprived of its elasticity, and  rendered
preternaturally fragde, is  often traversed
by small fissures, which thus break it up
into  scales,  having their margins project-
ing slightly into the lumen  of the vessel.
(Op. Cit. p. 15.)   From  the result of our
own investigations, we are rather disponed
to refer the origin of this change, as well
as many others generally attributed to the
lining  membrane  of the arteries,  to  the
delicate  substratum of  cellular  tissue
which  connects that tunic  to the  fibrous
coat; and in this opinion we are supported
by the  analogy furnished by the lesions of
other serous membranes, the majority of
which  have  their origin in the cellular
tissue,  uniting the proper  serous pellicle
to the  surrounding parts. The thickening
in question  may occupy the artery  to a
considerable  extent, either diffused  with
uniformity, or arranged  in  form of small
isolated  portions,  separated by irregular
lines ranging in various directions.  The
elevated points corresponding to the thick-
ened parts  of the membrane, are gene-
rally owing  to albuminous or other de-
posits  in the meshes of the  cellular tissue
situated  between the  lining  membrane
and the  fibrous tunic.   This condition is
oftenest  observed in the aorta, and the
primitive arterial trunks. Lobstein states
that he had never observed  it in the  arte-
ries  of the  upper parts  of the body, but
often in those of the lower extremities, in
which it existed in  form  of transverse
rugse,  imparting to the  inner  surface of
the  vessel  an appearance analogous to
that of the mucous membrane of the va-
gina, the folds of which have not been ob-
literated. (Op. Cit.  II. 551.)
   The same  species of   alteration  fre-
quently occurs in the fibrous tunic. It be-
comes preternaturally thickened;  is ren-
dered  so friable as to yield under a slight
degree of force; acquires an  unnatural
degree of density, and, withal, is deprived
of all  traces  of elasticity.  According to
Andral, it is sometimes so much thick-
ened, that it becomes as conspicuous as in
the  horse;  and  this we have witnessed
several times.   It would occur more fre-
quently, were it not, that in proportion as
the  changes  take place,  the  vessel be-
comes preternaturally dilated, thus  tend-
ing to give rise to more or less attenuation
of its  tunics, which would  otherwise pre-
sent an unusual degree  of  thickness.
   The cellular coat undergoes the  same
changes  as  the  common  cellular tissue,
when  exposed to  similar  influences.   It
loses  its filamentous  character, adventi-
tious deposits are formed  in its meshes,
and its  density is increased.  It  seldom, 
ARTERIES.  (Chronic Inflammation.)
393
however, becomes so friable as the inter-
nal and middle coats; and frequently when
they give way, it sustains the entire dis-
tending influence of the column of blood,
and  becomes  dilated to form  an  aneu-
rismal sac.
  The coats of the arteries sometunes un-
dergo a species of atrophy.   This is more
particularly true of the fibrous tunic, the
peculiar texture of which is rendered so
indistinct in such cases, that it is scarcely
perceptible even in the large arteries.  In
this condition, the vessels are less elastic
than natural; their volume is sometimes
diminished, and when exposed, they col-
lapse like veins.  In many cases, attenua-
tion is  associated with preternatural di-
latation ; and these alterations may be of
small extent  or they may affect nearly
the  whole  arterial system.  (See Dilata-
tion.)
  Atheromatous deposits in the coats of
the arteries.   There are few pathological
states of the arteries of more frequent oc-
currence, especially in advanced life, than
a deposit of a peculiar kind of matter be-
tween their internal and middle coats, de-
nominated  atheroma.  This  material  is
secreted by the vasa vasorum of the dis-
eased tissues, and varies much in its char-
acters.   It sometimes resembles pus, but
is often of a much thicker  consistence,
and may be compared to thick pap, or soft
cheese.  Small particles or flakes are fre-
quently intermixed with a thinner fluid,
and when rubbed between the  fingers, it
imparts something of a greasy or sapona-
ceous feel,  blended with which,  minute
gritty particles can be distinguished,  like
grains of sand, or the small calcareous
particles often discovered  in the matter
furnished  by a disorganized  bronchial
gland.  They probably consist  of minute
granules of phosphate of lime, which are
disseminated through the other materials
of the secretion.  This deposit is at first
disposed in small isolated points, of a yel-
lowish straw colour, situated beneath the
lining membrane; but as the matter accu-
mulates, the inner surface of the  artery
often assumes an uneven pustular appear-
ance, the membrane being elevated above
its  natural level.  Several of these  pus-
tules often  become  confluent, and  give
rise to  irregular patches of variable ex-
tent which render the surface of the ves-
sel  rugged and uneven.  Though situated
at first in the  meshes of the delicate cel-
lular tissue which unites the serous to the
fibrous  tunic,  the  influence of these col-
lections  sooner or later implicates  both
their structures, generally rupturing the
first and  giving rise to a small ulcer of
the kind described above,—impairing at
the same time the elasticity and cohesive-
ness of the fibrous coat,  and afterwards
destroying its  texture, so as to lay the
foundation of aneurism.
  This  atheromatous  secretion may be
confined to a limited portion of a single
artery, or it may be more  extensively dif-
fused,—the small yellowish points in ques-
tion being  unequally disseminated  over
the inner surface of these vessels to a con-
siderable extent, or through the whole ar-
terial system, especially in all the arteries
of considerable size.  The  quantity of
atheromatous matter  deposited  is  seldom
so great as to encroach materially upon
the capacity of the vessel,—yet this some-
times happens; and Hodgson states, that
he found the femoral  and emulgent arte-
ries obliterated by it in the same subject.
(Op. Cit.  p. 19.)  When  considerable, it
always  impairs the elasticity of the ves-
sel, renders its coats preternaturally fria-
ble, and is often  associated with more or
less dilatation.  It is unquestionably the
most fruitful source of spontaneous aneu-
rism ; and it sometimes gives rise to per-
foration or rupture of the larger arteries.
   The  precise nature of these  atheroma-
tous deposits is not  properly understood,
nor are the sentiments of pathologists in
accordance, in regard to the modifications
of vital action by which they are produced.
By some, the matter  of atheroma is con-
sidered analogous to tubercle, while others
regard  it as the inceptive  stage of the cal-
careous transformation, to which the  arte-
ries are so liable in advanced life.   The
fact that it  is  often  associated with this
latter condition is well established, small
granules,  or even scales,  of calcareous
matter  being frequently found occupying
the atheromatous patches or pustules.  The
question has also been mooted, whether  it
should  be considered as one of the multi-
farious  products of inflammation, or merely
as a consequence  of perverted nutrition or
secretion, originating in some other modi-
fication of vitality.   The solution  of this
question  can  only be obtained when  a
more accurate definition of what is meant
by inflammation  shall have  been  given
than any we now possess, since under the
vague  application of that term, at present
 in general use, it may be made to embrace
nearly  every known  lesion of the organ-
ization, or be restricted to a few of. them,
according to the particular views of the
pathologist. By some it has been asserted,
that this morbid secretion is deposited pri-
marily  in  the proper substance  of the 
394
ARTERIES.  (Chronic Inflammation.)
lining membrane. It has been represented
recently by Berard, that it is lodged be-
tween  the two  layers of this tunic, and
that if the disease  be  examined in the
early stage,  by  stripping off the mem-
brane,  the atheromatous points will all be
removed with it. (Diet, de Med.  IV.  132.)
There is  nothing to justify such an infer-
ence.  In the first place, we are not dis-
posed  to  allow that the lining membrane
is composed of two layers, although it has
been so represented by Haller  and  Mas-
cagni ; and when the appearance in  ques-
tion is observed,  it is in  consequence of
an attenuated stratum of the fibres of the
middle coat  being  peeled  off  with the
lining membrane,—an occurrence which
almost constantly happens in attempting
to separate  them.   We have repeatedly
detached the lining membrane entire from
the surface of these deposits, leaving them
behind, and we are satisfied,  from numer-
ous  examinations, that their primary seat
is the  cellular tissue situated between the
serous and fibrous coats of the artery.
   Steatomatous degeneration of the arte-
ries.  It would  be exceedingly difficult to
define accurately what pathologists wish
to express by the term steatomatous de-
generation of the arteries.  By some it is
not  distinguished from the atheromatous
secretion already described. Others  apply
the  term to  that matter when it assumes
a solid or consistent form; while by some,
the  steatomatous development of the ar-
teries  is said to  consist of irregular tuber-
cles or masses, of a yellowish fawn colour,
and of the consistence of bees-wax, cheese,
or  firm suet, occupying the substance of
the arterial tunics.  Having never observed
any pathological condition of the vessels
corresponding  to this definition of stea-
toma,  we shall be obliged to content our-
selves with an  enumeration of the  char-
acters which have been  ascribed to it by
others. According to Craigie, who speaks
of it as of frequent occurrence, the dis-
ease commences in form of small irregu-
lar patches, of yellowish or fawn-coloured
matter like wax, which appear on the in-
ner surface  of  the  proper coat.  As the
process of deposition advances, these be-
come thicker and broader. They coalesce,
and sensibly raise the  outer filamentous
coat;  while  by  their prominence interi-
orly, they diminish the capacity of the ar-
terial  tube.   At  the same time, the inner
membrane becomes irregular, opaque, and
shrivelled, and  the connexion  with the
fibrous coat being destroyed, it is detached
with great facility. (Treatise on General
and Path. Anat. p. 97.)  He also repre-
sents, that although the steatomatous de-
posit may occur probably  in any portion
of the arteries, it always commences pre-
cisely at  the point of their bifurcation,
and when  it occupies any extent of the
tube, it will be found to have begun at the
bifurcation, and spread thence along the
vessel.
   The steatomatous matter is sometimes
blended  with  small  earthy particles or
fragments  of ossification; but it  is often
unassociated with that deposit, and seems
to be of a homogeneous consistence. It
always impairs the  elasticity of the coats
of the artery,  diminishes their cohesive-
ness, and sometimes leads to a rupture of
the walls of the vessel, or to the develop-
ment of aneurism.   Although frequently
followed by ulceration, like the athero-
matous secretion of the vessels, the sweep-
ing assertion of Scarpa, that it is always
disposed to take on that process, must not
be admitted without some limitation.
   Next to the tendency of these  tumours
to destroy  the coats of the  artery, and to
occasion aneurism,  we may mention their
liability to encroach upon the capacity of
the vessel, and  impede or obstruct the
course of the circulation through it. These
effects are seldom produced, except when
the tumours attain a considerable size, in
which case, they may occasion the com-
plete closure of even the largest  arteries.
The most remarkable case  of this kind,
of which we have any account, is one de-
scribed by Stenzel.  (Dissert, de steato-
matibus aorta recus.,  in Hauler's Dis-
put. II. 527.)  The aorta was occupied by
two large  steatomatous tumours, one of
which implicated the arch; the other was
situated a  little lower down  in the upper
part of the  thoracic  portion of  the ves-
sel.  Such was the magnitude of these tu-
mours, that they distended the aorta until
it almost equalled the volume of the heart,
and encroached so much upon its calibre,
that there was  scarcely sufficient  room
left to  admit  the  passage of the  blood.
They  were firm and  unyielding to the
touch, and when laid open, were found to
be surrounded by a  thick  whitish mem-
brane ofa more compact consistence than
leather.   The cavity  was occupied by a
solid  substance resembling tallow or adi-
pose  matter.
   We  doubt much the propriety  of the
term applied by Stenzel to these  tumours.
It is highly probable, from the expression,
colore albicante ad incarnatum accedente
prsedita, striisque multis per totam super-
ficiem notata oculis occuribat nostris, and
other parts of the description, that they 
ARTERIES.  (Chronic Inflammation.)                  395
were truly large aneurisms of the aorta,
which  had  been cured spontaneously by
the successive depositions of fibrinous con-
cretions within the sac.   In  the article
Aorta,  p. 157,  we  have referred to two
cases reported  by Corvisart, which there
is  much reason to suspect were  of the
same nature, and several analogous exam-
ples might be cited.  From all the char-
acters which have been detailed in the re-
ports of such  cases, it is  much more ra-
tional to adopt the sentiment of Hodgson
—that  these  supposed  steatomatous  tu-
mours  were  merely examples of aneu-
rismal  sacs, which had been gradually ob-
literated by changes taking place within
them,  than any special degeneration or
new product developed within the proper
arterial tunics.  If  this view  of the sub-
ject be correct, it is improper to apply the
term steatoma to such  productions, and
the necessity  of circumspection will be
manifest, in order not to  confound them
with those deposits and   excrescences,
sometimes formed by the coats of the  ar-
teries, to which that appellation is more
properly applicable.  Of the effects of ste-
atomatous and various other tumours and
excrescences, which occasionally form in
the coats of the arteries, we  shall speak
under the head of Obstruction.
   Cartilaginous  transformation.    We
have already  spoken  of thickening and
induration  of  the  arteries.   When this
condition advances still further, the coats
of the vessel acquire a proper cartilagin-
ous consistence.  By those who have con-
tended that the calcareous transformation
of the  arteries is the result of a process
identical with  ossification,  this cartilagin-
ous condition has been represented as one
of the  intermediate stages between  the
simple  deposit of coagulable  lymph, and
its  final conversion  into  the  calcareous
plates which  occupy the  arterial  tunics.
The fact that  the two pathological states
are often found  associated, and that  the
contour of a calcareous scale is frequently
surrounded by  a portion of the tissue pos-
sessing the consistence of cartUage, seems
favourable to this inference.   Yet it must
be admitted, that in a large proportion of
cases, the development of the earthy de-
posits  is not preceded by  the  conversion
of the  tissues  into cartilage.   It  some-
times exists in small whitish or yellowish-
coloured isolated points,  intimately  ad-
herent  to the  lining membrane; but  fre-
quently  it extends to all the tunics, occu-
pying them to  a considerable extent,  and
converting  the artery  into a firm rigid
and inelastic cylinder.  Though probably
a consequence of  chronic  inflammation,
this cartilaginous state is never associated
with any preternatural redness or injec-
tion of the vasa vasorum.
  Calcareous transformation.   Ossifica-
tion  of the  arteries.  (Lithiasis arteria-
rum.)  Decidedly the most common of all
the pathological states of the arteries is,
the development, within their tunics, of
small irregular plates, or scales, of calca-
reous matter, constituting what is deno-
minated ossification. It occurs so frequent-
ly in advanced life, that according to Bail-
lie,  it  is oftener observed at that period
than the natural condition; and Bichat
estimated the ratio of cases  in which it
exists after the age of sixty, as seven in
ten.   The form, size, and arrangement of
these earthy deposits are almost infinitely
variable.  Examined in the inceptive stage
of their formation, they generally consist
of minute isolated opaque points, or specks,
of a yellowish or whitish colour, often in-
corporated with more or less of the athe-
romatous matter already described.  Some-
times  the coats  of the arteries present
small  opaque patches of a  cartilaginous
consistence, the centre of which is occu-
pied by one or more small earthy granules.
But when their development has advanced
further, the coats of the  artery are ren-
dered  rough, rigid, and inflexible, by nu-
merous irregular plates or scales of a firm
earthy consistence, which vary in size  and
figure, but  generally have their surfaces
flattened, and • that which looks towards
the cavity of the vessel smoother and more
uniform than the other. If the transforma-
tion has advanced  very far, the edges of
these  plates  approach so  near to each
other, as scarcely to leave any  of the ar-
terial  tunics of a healthy consistence be-
tween them, the whole extent of the  dis-
eased vessel being  converted into a firm
unyielding  calcareous cylinder,  totally di-
vested  of  its  natural  attributes,  which
when forcibly compressed, may  be broken
down  into  numerous fragments like an
egg-shell.  Should the transformation be
less considerable, the points or  scales are
more sparsely arranged, and are often se-
parated by  portions of the  artery of con-
siderable extent in which  the  tunics re-
tain their healthy characters. In some in-
stances, the calcareous matter  is not de-
posited  in form of flattened scales, but is
disseminated in thick projecting masses,
exceedingly rough  and  irregular upon
their surface, exhibiting more of the char-
acters  of small irregular pebbles, than of 
396
ARTERIES.  (Chronic Inflammation.)
a proper organic transformation. This va-
riety is, however, of much rarer occurrence
than the preceding, and is seldom observ-
ed, except in the angle formed by the bi-
furcation  of two vessels.   There is still
another form  assumed  by these concre-
tions, which has been supposed to have  a
different origin from either of the others.
It consists of numerous circular masses,
passing partially or completely round the
vessel, and corresponding to the direction
of the fibres  of the  middle coat  These
fragments are generally interrupted by
portions of the coats of the artery which
retain something of their healthy texture,
and thus  impart to  the vessel a kind of
articulated appearance.   They have  been
supposed to  consist especially of a trans-
formation  of the fibrous  coat, the scales
and plates already described having their
origin either in the serous coat or the cel-
lular tissue by which its adherent surface
is  attached.   These annular concretions
are never  found in the aorta, and are  most
frequently observed  in the femoral and
other arteries  of tbe lower extremities.
  The question as to the precise seat of
the calcareous or  osseous transformation
of the arteries still remains unsettled. De
la Sonne  long since  affirmed, that the de-
posit  takes place in the substance of the
lining membrane (Mem. de l'Acad. Roy-
ale. 1756.),  and  this  opinion  has been
more  recently  advocated by Hodgson (Op.
Cit.  p. 24.), Cruveilhier (Essai sur V-
Anat. Pathologique. II.  67.),  Meckel
(Manuel d'Anat. 1.154.), Craigie (Gene-
ral and Path. Anat. p. 91.), Guthrie (Dis-
eases and  injuries of the arteries, p.  23.),
and  Berard  (Diet, de Med. IV. 129.).
Bichat located it in the outer surface of
that membrane (Anatomie Generate. Edit.
par Blandin.  II. 63.), and Scarpa (Tratto
sulV aneurism),  Andral (Precis d'Anat.
Path. II. 381.),  Otto (Lehrbuch der Pa-
thologist. Anat. I 340.), Lobstein ( Trai-
te d'Anat. Path. II.  561.), Breschet (in
Meckel, Loc.  Cit.), Hope (Cyclopadia of
Pract.  Med.   Art.  Arteritis),  and  Cop-
land (Diet, of Pract. Med. Art Arteries),
represent, that the disease commences in
the  delicate   filamentous  tissue  which
unites the serous to the fibrous coat of the
arteries.   The correctness of this opinion
seems to  be confirmed both by dissection
and the analogies furnished  by other se-
rous membranes; nor are we disposed to
admit the  existence of the two laminae of
the lining membrane of the arteries re-
cognized  by  Haller,  Mascagni,  Cru-
veilhier, and Berard, and which  the
two latter individuals have appealed to, in
support of their pathological views upon
this point
   By some, it has been supposed that this
species of transformation sometimes com-
mences also in the  fibrous  coat.  Those
who have adopted this opinion, affirm that
when  the  fragments exhibit an annular
arrangement and extend round the entire
circumference of the vessel, it is owing to
the metamorphosis of the circular elastic
fibres of the vessels  into these calcareous
rings.   Blandin has indeed  affirmed, that
the ossification of the arteries which is of
such frequent occurrence in old age, al-
ways takes place in the fibrous coat, while
that which is  observed  at an  earlier pe-
riod, commences between this tunic and
the lining membrane.  (Bichat.  Anat.
Generate. II.  67. Note.)
  However this may be, the coats  of the
vessel in which the earthy deposit is made,
experience important modifications.  The
lining membrane is elevated upon the sur-
face of the concretion,  and in the early
stages of the disease, adheres intimately
to that face of it which  is directed in-
wards, in form of a  thin  pellicle, so as
to be interposed between the calcareous
scale  and the  column of blood.  Bichat,
however, was incorrect in affirming that
it  seldom becomes  destroyed.   Contrary
to this,  it is often found where the plates
are numerous and large,  that the lining
membrane  presents  numerous  cracks or
fissures,  through which the  edges  and
angular prominences of the adventitious
masses  project, so as to be placed in di-
rect contact with the  stream  of blood.
This latter fluid, indeed, sometimes insi-
nuates itself beneath the edges of the rup-
tured membrane in  the vicinity of these
crevices, and imparts to it a dark ecchy-
mosed appearance, which upon superficial
examination  might  be  mistaken for in-
flammation.  The fibrous coat is divested
of its natural elasticity  and  pliancy;  it is
sometimes increased in thickness, and ren-
dered  preternaturally friable;  but more
frequently, it  either  experiences a consi-
derable degree of atrophy, or becomes par-
tially or completely supplanted by the cal-
careous deposit  These changes, together
with those  which take place in the lining
membrane,  so enfeeble the coats  of the
artery, that they either yield before the
lateral distension occasioned by the blood,
and lead to the development of aneurism,
or they become ruptured,  and a fatal he-
morrhage takes place.  The cellular coat
though less liable to  these changes than
the others, often has  its texture  consider-
ably modified, and in some instances, the 
ARTERIES.  (Chronic Inflammation.)                  397
adventitious deposits  encroach so much
upon it, as to leave but few vestiges of its
natural structure.
  There is probably no portion of the ar-
terial system exempt from this calcareous
transformation,  though  it occurs much
more frequently in some arteries than in
others.  It attacks the aorta oftener than
its several branches, and as a general rule,
the latter are more liable to it than their
several divisions and  subdivisions.  Ossi-
fication of the aorta is indeed so common
in advanced life, that it is perhaps more
frequently  observed than its natural con-
dition.  It  should, nevertheless, be  ob-
served, that cases occasionally occur, in
which this vessel is entirely  exempt from
this change, whde the arteries of the  ex-
tremities are extensively  ossified.  Lob-
stein states that he has witnessed several
such examples, and some of the same kind
have  fallen under our own observation.
The extent to which it becomes thus af-
fected is sometimes so considerable  that
it is converted,  to the extent of several
inches, into a  solid earthy cylinder, so
rigid and unyielding,  as to accommodate
itself with difficulty to the ordinary flex-
ures of the body.  Ossification of the co-
ronary arteries is very often observed.  It
 was long  ago particularly  described by
 Crell (Obs. de arteriar. coron. instar os-
 sis induratis), and was besides noticed by
 Bellini, Meckel, Senac, Morgagni,  and
others. Much  importance was attached
 to its influence on the heart, and more re-
 cently it  has  been  supposed by  Parry
 and others  to constitute the cause of an-
 gina pectoris.  The  arteries of the neck
 and head  are also often found  ossified,
 especially  the common and external ca-
 rotids, and the branches of the latter.  The
 trunk  of the internal carotid seems to be
 less frequently affected, and Lobstein re-
 marks, that he  has seldom discovered
 points of ossification  involving any other
 portion of  it, than the curvature which is
 lodged within the petrous portion of the
 temporal bone.  The vertebral  artery is
 very often  the seat of this calcareous de-
 posit  Morgagni remarks,  that  he  has
seen the basdar artery presenting points
of ossification, and we have more  than
once witnessed the same condition of this
vessel, as well as of most of the arteries
of the brain, in aged persons.   It often
lays the foundation  of apoplexy in ad-
vanced life, and predisposes to other affec-
tions  of this organ.   Sometimes,  indeed,
this morbid alteration  seems  to  extend
even to the small twigs of the vessels of
the brain.   In one case observed by Loc-
    vol. ii.          '34
stein (Traite d'Anat. Path. II. 557.), the
minute ramusculi penetrating the medul-
lary substance of that organ were so firm-
ly ossified, that in attempting to slice it,
they resisted the  scalpel, and  could be
drawn out in form of minute osseous tubes
of a filamentary appearance.   The indi-
vidual's age was  not  more  than forty-
seven, and he had not died of any disease
of the brain.  It is not unusual to find
small masses of these earthy concretions
occupying the origin of the  innominata,
and the subclavian arteries.  They some-
times project considerably into the  cavity
of the vessel, and Andral thinks, may be
instrumental in  producing the difference
of the pulse in the two wrists in old per-
sons.  Similar masses also exist in the bi-
furcation of other vessels, and in some in-
stances, they no doubt tend to modify the
currents of blood at those points.
   We have often found the cceliac artery
extensively ossified, but  have never ob-
served this lesion in any but its splenic
branch, in which it  is of common occur-
rence.  Andral remarks, that it is rarely
observed in the hepatic artery, and the co-
ronary of the stomach; and Lobstein de-
clares that  he had  never found either of
those vessels affected  with  it.  In  the
emulgent arteries it is common; also in
the spermatics.   The trunks of the me-
senteric arteries are also frequently af-
fected,  but  their branches very generally
escape.  The museum of the University
of Maryland contains a specimen of ossi-
fication of the branches of" the hypogastric
artery, and  several examples were observ-
ed by Haller, who  also witnessed this af-
fection in the arteries of  the penis.  It is
likewise very common  in the uterine ar-
teries, and  according to Lobstein,  some-
times even affects their smallest ramifica-
tions.   The same author remarks, that in
one case, he found the uterine surface  of
the placenta presenting numerous points
of ossification, which, on being carefully
examined,  were found to  correspond to
the vascular ramifications, and presented
themselves in form  of osseous ramusculi.
(Op. Cit. p. 556.)
   The liability of the arteries  of the ex-
tremities to this alteration is  well known.
 Yet  it is somewhat remarkable, that  it
 should  occur so much  more frequently in
 the lower  than in the  upper members.
 Loestein concludes,  from numerous ob-
 servations, that the  instances  in which the
 femoral arteries and its branches are found
 ossified, compared  to those in which the
 brachial artery  and its  numerous divisions
 are affected, may be estimated in the ratio 
396                  ARTERIES.  (Chronic Inflammation.)
of 30 to 1; and he  remarks, that in two
individuals—one aged one hundred and
four, the other ninety-six, in whom he ex-
pected to find all  the  arteries ossified,
those of the upper  extremities furnished
no trace of this condition, while the femo-
ral arteries  and their branches were af-
fected throughout nearly their whole ex-
tent.
   Bichat, assuming the ground that the
vessels which circulate black  blood are
not liable to ossification, affirmed, that the
pulmonary artery is  exempt from this con-
dition.  The truth of this assertion is con-
tradicted by  several examples, recorded
both before and since his time, of ossifica-
tion of different veins, and also of a simi-
lar affection of the pulmonary artery, and
tlie valves of the right side of the heart-
Yet it must be confessed, that such in-
stances are  comparatively rare.   In up-
wards  of two thousand  bodies  which we
have either  examined or witnessed when
opened, we  have never seen  more  than
small  cartilaginous  points affecting the
coats of this artery, some  of which con-
tained minute particles of calcareous mat-
ter.   It is stated by Cruveilhier (Essai
sur VAnat. Path. II. 53.) that Gemma and
Veslingius  discovered small osseous con-
cretions at  the orifice of the pulmonary
artery.  In  a case  observed  by Chomel,
this vessel was occupied both  externally
and internally by calcareous masses. (Hist.
de l'Acad. Roy. des Sc. 1707.  06s. Anat.
3.   Also, Morgagni, XXVII. 20.)  Mar-
chetti found an earthy concretion occu-
pying the orifice of the pulmonary artery
of an individual who died of dropsy. (Bo-
netus. Sepulchret.  Lib. III. sect. 21. J 22.)
Morgagni observed a case in which the
orifice of this vessel was nearly closed  up
by such concretions (Epist. xxvii.), and
Grimm reports an example of ossification
of the pulmonary artery of an ox. (Ephem.
Nat. Cur.  Dec. II. An. III. Obs. 38.)  In
the  body of a female, aged seventy-four,
Stoll found numerous small granules and
points of ossification disseminated over the
internal surface of this vessel. (Ratio Me-
dendi. I. 136. Sect. 9.)  According to the
report of Lobstein,  an example of this
species of transformation is contained in
the  Anatomical Museum at  Strasbourg.
(No. 434.)  The osseous mass was seven
lines in length, by five in breadth, and
three in thickness.   It was situated at the
orifice of the ductus arteriosus, and was
covered  by the lining  membrane of the
artery.  The whole length of  the ductus
arteriosus was also ossified.   He observed
a second case of the same kind, except
that the ossification was partial.  (Traite
d'Anat. Path. II. 562.)  Otto also refers
to a specimen of ossification of the  pul-
monary artery, which he witnessed in the
Anatomical Museum of Freiburg.  It oc-
curred in a young subject who fell a vic-
tim to consumption.  (Lehrbuch der Path.
Anat. I. 341.)  Besides these, the follow-
ing cases have been  referred to by Hodg-
son and Otto, as examples of ossification
either of the  pulmonary artery  or its
valves: Senac (Traite  de  la structure,
&c., du cceur. IL 402.), Haller (Opusc.
Path. Obs. LIX.), Burnet (De Polyposib.
concret. in pect. morb. Altd. 1729.), Mora-
enheim ( Wiener Beitrage. XI. 215.), Pohl
(De ossif vasor. praternat. Lips. 1774),
Baader (Obs. Med.  incis. cadaver, ana-
tomie illustrat.  Frib. 1775.), Bach (Rich-
ter's Chirurg. Bib.  VIII. 498.
   It is thus manifest, that the transforma-
tion is liable to take place in every por-
tion of the arterial  system, and notwith-
standing it is but rarely observed in some
of the arteries, no one of them  possesses
an entire immunity.  According  to exten-
sive investigations made by Lobstein, the
following is  the order of liabdity  of the
different arteries to  undergo this  altera-
tion:
   "The arch of the aorta;
   The angle formed by  the division of
this artery into the two iliacs;
   The thoracic aorta;
   The splenic artery;
   The abdominal aorta;
   The femoral artery and all its branches;
   The spermatic arteries;
   The internal iliac and its branches;
   The coronary arteries of the heart;
   Some of the branches of the subclavian;
   The angle of division of the common
carotid;
   The inflexions of the internal carotid;
   The cerebral  arteries in a state  of car-
tilaginification.
   The branches of the external carotid;
   The arteries of the walls of the thorax
and abdomen;
   The brachial artery and  its ramifica-
tions ;
   The ramifications of the umbilical ar-
tery;
   The small arterioles which plunge into
the substance of the brain;
   The pulmonary artery."—(Traite  d'-
 Anat. Path. II. 558.)
   Although  ossification of the arteries has
been generally regarded  as a kind of in-
 separable  appanage of old age, it is not
 exclusively confined to this period of life;
nor does it always exist  even in the most 
ARTERIES.  (Chronic Inflammation.)
399
aged.  We have several times had sub-
jects on the  dissecting table, apparently
of great age, in whose arteries no traces
of this transformation could be discovered.
Andral remarks that he examined a fe-
male of upwards of eighty, without find-
ing any indication of ossification, notwith-
standing the  bronchial ramifications were
converted into  firm cartilaginous and os-
seous tubes.  (Precis  d'Anat. Path.  II.
380.)  Nor are cases  wanting, in which
the  arteries  even of young subjects have
been found  affected with this condition.
Cowper found  the arteries ossified in a
man aged thirty years. (Philosoph. Trans-
act.  1705.  No. 299.)   Portal  remarks
that it  is sometimes met with in young
subjects, in whom the ossification of the
bones is not far advanced. (Cours. d'Anat.
Med. III. 133.)   Young found the tempo-
ral artery of  a child, only fifteen months
old, converted into a complete calcareous
tube. (Hodgson.  Op. Cit. p. 27.)  Wilson
observed a case  in which the aorta was
ossified, in a child  aged three years, and
other cases of an analogous character have
been observed  by Andral.  In  one in-
stance,   he   discovered  several  osseous
plates occupying the aorta of a little girl
of eight years old; and he observes, that
 in four or five subjects, between  the ages
 of eighteen and twenty-four years, he had
 witnessed a simdar transformation of the
 arteries.  He likewise met with consider-
 able ossification of the superior mesenteric
 artery of an  individual aged about thirty
 years. (Precis d'Anat. Path.  II. 380.)  In
 a female aged seventeen, Otto discovered
 inceptive ossification of the aorta. (Seltene
 Beobachtung. Heft II. 66. No. xxix.)  In
 other subjects,  of not  more than thirty
 years of age, he observed ossification of
 the cerebral arteries; and he subjoins, that
 this condition of the  semilunar  valves of
 the aorta, and of the  ductus arteriosus, is
 not uncommon in young persons. (Lehr-
 buch der Path. Anat.  I. 341.)  For other
 examples of  a similar character, he refers
 also to Bohmer (Obs. anat. rarior. Fasc.
 1. Praef. p. ix.), and Penada (Saggio di
 osservaz. II.  22. Padova, 1800.)
   It will be  seen from these facts, that it
 is difficult to designate with certainty any
 particular age  at which this transforma-
 tion of the arterial tunics takes place.  It
 seems to vary indeed in different countries.
 It is stated by Lobstein, that in the neigh-
 bourhood of  Strasbourg, not only ossifica-
tion of the arteries, but also of the uterus,
and thyroid gland, is often observed at the
age of thirty.   This  is certainly  earlier
than it occurs in most other countries, in
which it will  seldom be observed before
the age of fifty or sixty.   Indeed, it has
been  represented as being comparatively
rare in some  climates.  In the West In-
dies, Stevens affirms that ossification of
the arteries is by no means common (Med.
Chir. Transact. V. 434.);  and  Otto re-
marks that it  is seldomer observed in Si-
lesia  than in  some  other quarters.  (Op.
Cit. p. 341.)  He thinks that the free use
of wine, cider, and strong alcoholic drinks,
in France and England, may be the cause
of its greater frequency in those countries.
It has been supposed by many, that the
rachitic and arthritic diatheses are fruitful
sources  of this osseous  transformation,
and by others it has been imputed to the
influence of syphilis and mercury. It will
be seen, however, that the agency of most
of these causes is in no degree in relation
with the effect—ossification of the arte-
ries being, as previously stated, too com-
mon  to derive  its  origin  from either of
these influences.  By Andral, especially,
a gouty diathesis has been supposed to ex-
ercise  an important agency in the  de-
velopment of this condition. Setting out
upon the well-known tendency of this dis-
ease to give rise to calcareous concretions
of the joints  and  to  urinary calculi, and
taking into account the facts  established
by Magendie, that when carnivorous ani-
mals are fed upon aliment containing no
azote,  both uric acid  and  phosphate  of
lime disappear from the urine, he reasons,
that  the  tendency of a  too liberal  indul-
gence in an aliment abounding with azote,
as is the case  with  gouty  persons,  is to
give rise to a preternatural generation  of
these materials, and their consequent de-
posit, either  in form of urinary calculi,
gouty concretions of the joints, or ossifica-
tion  of the  arteries.   According to this
 view of the subject the  first step in the
 morbid  process is,  a modification in the
 properties of the blood, and the deposit of
 earthy matter, and the  other  attendant
 phenomena are merely consecutive.  The
 adoption of this hypothesis would neces-
 sarily give to the diathesis in  question an
 almost universal influence, since, as has
 been already remarked, a large proportion
 of individuals in advanced life, are  affect-
 ed with ossification of the arteries.  It is
 possible, however, that a too  free indul-
 gence in such a diet  may give rise  to
 changes of the kind alluded to, yet we are
 satisfied this may take place without any
 participation of  a gouty diathesis,  and
  merely as a consequence of modifications
 of nutrition  and secretion, induced either
  by the quality or quantity of aliment, the 
400
ARTERIES.  (Chronic Inflammation.)
influence of climate,  age,  and other cir-
cumstances. Crell, Morgagni, and others,
long since  referred these osseous produc-
tions to the influence of inflammation—a
sentiment  in which they were confirmed
by the traces of redness and other charac-
ters of that process, with which they are
sometimes  associated.  This opinion has
been  espoused by some modern patholo-
gists, and  especially by Broussais  and
Rayer. The chief arguments which have
been  adduced  in  its support have  been
drawn from  the  analogies furnished by
other serous and fibrous tissues, in which
it is alleged similar  productions are not
unfrequently found.  The pleura, pericar-
dium, dura mater, &c,  are all occasion-
ally the  seat of  the accidental develop-
ment of plates of bone of variable magni-
tude,  which it is usual to attribute to in-
flammation.  Hence it is assumed that os-
sification of  the  arteries may be legiti-
mately ascribed to similar changes excited
in the serous and  fibrous tunics of those
vessels by  inflammatory action.  That the
inference is true in some cases, it would
be  as difficult to  disprove, as it would to
demonstrate that  it is so in all.  Numer-
ous facts clearly show, that under particu-
lar modifications of vital action, inflamma-
tion is capable  of giving rise to a species
of osseous transformation of several of the
animal structures, and there is no reason
to consider the tissues  of the arteries  as
entirely exempt from these changes.  Yet
when we take  into account the extreme
frequency  of ossification of these vessels,
its constant tendency to occur in advanced
life, when  the liability to inflammation is
very much diminished, and the total ab-
sence of all  the  phenomena of that  pro-
cess in a  large proportion of cases,  it is
manifest that it must, in a majority of in-
stances at least,  derive its origin  from
some other cause.   What this cause is, it
is difficult  to explain.   We may legiti-
mately refer it to some modification of nu-
trition or secretion, yet this offers no ex-
planation of  the secret  operations  of vi-
tality by which these- changes are induced.
The constant distension of the coats of
the arteries,  however,  together with the
modifications of their textures, and of the
blood they circulate, which take place  as
age advances, are all circumstances which
dispose them in a peculiar manner to be-
come the seat of these  adventitious depo-
sits ; and while most  of the other tissues
are rendered  firm and rigid in advanced
life, by the deposit of elements differing
in kind from those which belong to them
in  earlier  years,  by analogous  modifica-
tions of nutrition and secretion, the coats
of the  arteries under  the  same circum-
stances, become the seat of calcareous de-
posits.   As  to  the redness and other ap-
pearances of mflammation which are oc-
casionally observed in the vicinity of these
osseous productions,  they are  generally
altogether  consecutive, and the redness
not unfrequently consists in a small quan-
tity of blood insinuated beneath the edges
of the  ruptured lining membrane of the
artery.
   How far  these productions should be
considered  as  identical with  bone,  is a
question which is not yet satisfactorily de-
cided.  So far as their hardness, and their
earthy constituents  are concerned, they
certainly possess a  strong  analogy with
that structure.  This is confirmed both by
simple inspection and chemical analysis;
for although the results obtained by differ-
ent chemists vary somewhat, they all con-
cur in showing that the osseous produc-
tions of the arteries contain some of the
principal constituents of bone.   Thus, ac-
cording to  the experiments of Brande,
they are composed  of phosphate of lime
65.5, animal matter, consisting of albumen
with a few traces of gelatine 34.5. (Hodg-
son, p. 26.) Vauquelin obtained phos-
phate of lime 65.3, carbonate of lime 6.5,
soluble salts 4.0,  and animal matter 24.2.
(Rayer. Archives Generates. I.) The an-
alysis of Lassaigne furnished mucous ani-
mal matter 50,  phosphate of lime 47£, car-
bonate of lime 2, and  some traces of sul-
phate of lime.   The slight difference in
these results indicates that the proportion
of the  component elements varies in dif-
ferent  specimens; and a simdar variation
is observed  in the composition of natural
bone.
   Those who have assumed the identity
between these productions  and natural
bone, maintain, that coagulable lymph is
first poured out by  the inflamed tissues;
that this is solidified, gradually converted
into cartilage,  and is finally, by the depo-
sit of earthy matter, converted into bone,
precisely as ossification takes place in the
bones  themselves.   Morgagni supposed
that the purulent matter which is some-
times deposited beneath the lining mem-
brane  is gradually transformed into these
calcareous plates;  and Haller inferred
that the atheromatous secretion is by de-
grees converted into a firm coriaceous or
cartilaginous tissue, which by subsequent
changes acquires  the  properties of bone.
There is nothing to justify either of these
inferences.  Although calcareous deposits
are occasionally found in the  midst of a 
ARTERIES.  (Chronic Inflammation.)                   401
portion of the  arterial  tunics of a carti-
laginous consistence, they are much oftener
met  with  without any such  accompani-
ment;  and notwithstanding earthy con-
cretions are sometimes formed in the midst
of a collection of atheromatous matter,
such instances are so comparatively rare
as to show that there is no necessary con-
nexion or dependence  between  the two
formations.  The only analogy, indeed,
between these calcareous productions and
bone, consists in their chemical composi-
tion ; for although they are both composed
of phosphate and carbonate of lime, and
animal matter, the adventitious produc-
tions present no  traces of a fibrous or la-
mellated structure, but have a greater an-
alogy with a rude crystal or petrifaction,
the  calcareous matter being deposited in
the  interstices of the natural  structures,
 where it accumulates to such a degree  in
some cases as to completely supplant them.
   The influence of these transformations
 upon the physiological acts of  the  organs
 is exceedingly difficult  to estimate.   It
 will vary, indeed, according to the vessels
 affected, and the extent of their implica-
 tion.   We shall have occasion under an-
 other head to notice  the  tendency of the
 calcareous masses  to occasion narrowing
 and obstruction of the calibre of the arte-
 ries; and  their agency in the production
 of ulceration  and aneurism of these ves-
 sels has been  already  considered.   How
 far this condition influences the circula-
 tion of the blood cannot be ascertained.
 Bichat affirmed that  ossification  of the
 aorta is  capable of modifying this func-
 tion, but that  the same  condition  of the
 arterial trunks,  branches, ramifications,
 &c, does not occasion the slightest de-
 rangement (Anat. Generate. II. 66.) The
 latter part of the proposition is too palpa-
 bly erroneous to  require refutation.  The
 influence  of ossification of the arteries in
producing apoplexy,  epilepsy, palpitation
of the heart, derangements of the pulse,
coldness and inactivity  of the extremities,
 gangrene, &c, is so well known, that we
cannot doubt  for  a  moment  that when
these vessels become extensively involved
in this species of transformation, more or
less disturbance  of function must  be the
necessary consequence.  It seems, indeed,
that it may in  extreme instances produce
a  complete annihilation  of all pulsation.
A case of this kind has been  reported by
Berryat. The subject of it was a female,
in whom not the slightest indications of
pulsation could be perceived, either in the
vicinity of the heart, or any other part of
the system, even after  active  exercisa,
                 34*
and while the body was heated.  (Hist, de
l'Acad. Roy. des Sc. 1748.  p. 61.)
  But while these  truths are incontesta-
ble, it must be confessed, that many aged
persons affected  with ossification of the
arteries even to  a great extent, experi-
ence no disturbance of function from that
cause, and enjoy as good health as is  usual
at their period of life.
  Tuberculous matter is probably seldom
deposited  in the tissues composing the ar-
teries.  In our numerous examinations we
have  never  met  with a single example,
although  we have  repeatedly observed
small masses of tuberculous degeneration
adherent to the outer surface of these ves-
sels.  Sandifort, however,  seems to have
met with this affection (Obs. Anat.  Path.
Lib. IV. cap. x. p. 109., and  Mus.  Anat.
I. 242.  No. IX.),  and Otto  also affirms
that he observed scrofulous  tumours so in-
timately connected with the coats of the
aorta and carotid artery, that they could
not be isolated, except by dividing the ex-
ternal tunic. (Lehrbuch der Path.  Anat.
I. 343.)
   Melanotic matter is likewise very rarely
observed  in the coats of the arteries.  It
is true that they are sometimes found af-
fected  with  small dark-coloured  points,
which seem to occupy the  space between
the  internal  and  middle tunics; but it is
probable, as Bouillaud iias  remarked, that
they  are  merely small  masses of  blood,
which have been some time extravasated
 in the substance of the coats of the ves-
sel.   A case has nevertheless  been deli-
neated by Cruveilhier, in  which, besides
numerous masses of melanotic  matter oc-
cupying  different  portions of  the  heart,
one is  seen implicating the  coats  of the
pulmonary artery.  (Anatomie Patholo-
gique de VHomme. Liv. XIX.  plate 4.)
   Cancerous degeneration, so far  as we
are aware, has only been found in  a few
 instances  in the arterial system.  Of the
 cases to  which  we allude, one was ob-
 served  by Velpeau, and has been quoted
 in the article Aorta, p. 163, and the  others
 by Laennec. (Auscult. Mediate. II. 684.)
   The various  lesions which have been
 described in the course  of  these remarks,
 though included under the  titles of acute
 and  chronic  arteritis, cannot with propri-
 ety be all referred to inflammation.  Many
 of them unquestionably have that origin,
 yet there are several others, which seem
 to be owing to modifications of nutrition
 and secretion, in the production of  which
 inflammation has no agency.  What the
 precise modifications of vital action may be,
 by which such a diversity of consequences 
402
ARTERIES.  (Inflammation, its Sympt. and Diagn.)
is produced,  cannot be  satisfactorily  as-
certained, and in the absence of positive
information, we must be satisfied to study
the effects, until the advances of patholo-
gical science shall  make us acquainted
with those mysteries of vitality, which are
at present shut  out  from our comprehen-
sion.
   Symptoms and Diagnosis of Arteritis.
The symptoms of acute  inflammation of
the arteries are so analogous to those com-
mon to many other affections,  that it is
not easy to discover any traits sufficiently
constant and characteristic, to distinguish
it from diseases  of  other portions of the
organization.   The difficulty is  greatly
augmented by the deep  seat of some of
the  principal vessels, by  the complex re-
lations of all of them, and by their pecu-
liar liability to have their functions thrown
into disarray, by almost every disturbance
affecting other tissues and organs.   We
shall first enumerate the principal symp-
toms that accompany the  disease  in its
different stages and modifications,  and af-
terwards consider how  far any of them
can be relied on in forming a diagnosis.
   Acute inflammation occupying a small
extent merely of a  single artery, is often
unattended with any  very striking  dis-
turbance of either a local or general char-
acter.  Thus,  after  the application  of a
ligature, which always occasions more or
less inflammation of the vessel,  there  is
often   no very  palpable  alteration  of
the part: there  is but little  increase of
sensibility, heat, or tumefaction, and the
 whole  process of obliteration may be ac-
 complished, without the supervention of
 any febrile or other constitutional disturb-
 ance.  It is far different, however, when
 the inflammation is more extensively dif-
 fused,  and when it seizes with considera-
 ble intensity upon  a  large extent of the
 arterial  system.   Under  such  circum-
 stances,  it is attended with violent fever
 of the inflammatory kind, the symptoms
 of which vary much in the progress of the
 disease.  The modifications thus accruing,
 are partly attributable to the influence ex-
 erted upon the vital powers, and in  part
 to changes taking place in the structures
 of the vessels themselves, and  the blood
 they circulate.  The first symptoms mani-
 festing a general disturbance of the  sys-
 tem,  are commonly slight  chills, alter-
 nating  with  flushes  of heat  which are
 speedily followed by intense fever, attend-
 ed with violent pulsations of the heart and
 arteries, a red suffusion  with capillary in-
  jection of the  skin,  burning heat, un-
 quenchable thirst,  extreme  restlessness,
jactitation  and general distress, laborious
and hurried respiration, and sometimes a
dry harassing cough.   W hen  the  inflam-
mation is seated in the aorta, there is, ac-
cording to Joseph Frank, a sense of heat
beneath the sternum, or in the vicinity of
its  upper extremity;  and  Spangenberg
and  Kreysig  remark, that  the  patient
sometimes complains  of a sensation like
that of hot iron  drawn along the course
of the aorta, descending as low as the cru-
ral arteries. When the arteries of the ex-
tremities are affected, there is pain, some-
times simulating  rheumatism, sometimes
of a burning kind, in the course of tlie in-
flamed  vessel, which  either  fixes itself
with considerable intensity upon  a parti-
cular part, or is unequally diffused.  The
affected  point  is tender to the touch, and
if the vessel be superficial, there is gene-
rally increased volume and  hardness of
its walls, perceptible through the integu-
ments.   There is likewise increased heat,
and sometimes more or less  tumefaction,
with a distressing sense of throbbing.  At
first the pulsation is  preternaturally vio-
lent along the whole extent of the  in-
flamed artery, but in proportion as its tu-
nics, and the blood within, become altered,
the  inordinate throbbing and expansion of
the  vessel is confined  to the portion above
the  principal  seat  of the inflammation,
while lower down  the pulsation becomes
feeble,  and when obliteration takes place,
finally ceases  altogether.   Should the ca-
rotid artery be affected, there will be pain
and tenderness along the side of the neck,
 attended with violent  pulsation in that re-
 gion and in all the arteries of the head —
 distressing cephalalgia, vertigo, flashes of
 light before the eyes or obscuration of vi-
 sion, ringing or roaring in the ears, and
 in  some cases violent delirium, convul-
 sions, or even apoplexy. In one of Frank's
 cases,  the patient  complained of every-
 thing wearing a green colour; and in most
 instances, whatever artery is affected, the
 corresponding veins  and capillaries  are
 preternaturally turgid in the  first stage of
 the disease, owing to the blood being pro-
 pelled  into them with increased impetu-
 osity.
   From the first onset of the disease, the
 heart beats violently, and is  affected with
 frequent palpitations,  especially if the in-
 flammation  implicates  its  lining mem-
 brane.  There  are forcible  pulsations  or
 throbbings of the whole  arterial system,
 and during the whole of the  first stage,
 the pulse is full, strong, tumultuous, bound-
 ing, and sometimes exceedingly frequent.
 J.  P. Frank  remarks, that  it  is in some 
ARTERIES.  (Inflammation, its Sympt. and Diagn.)
403
instances as  tense  and hard as a metal
wire; and in one of the cases observed by
him, its beats fluctuated from 185 to 200
in a minute.  It also frequently intermits,
or presents a kind of double stroke, and in
some  instances, if blood be drawn, both
the hardness and frequency are increased.
The respiration is hurried,  embarrassed,
and occasionally so difficult as to amount
to distressing orthopncea.   There  is also
a  troublesome dry cough, and sometimes
hemoptysis; and if the disease be seated
in the aorta, any sudden movement of the
body  occasions an increase of pain, and
augments  the  general  suffering. The
tongue is red  on the  edges,  its papillae
prominent, and its base and middle coated
with  a thick fur.  The thirst  is intense
and unquenchable;  the  stomach some-
times  irritable; the bowels  constipated,
and the urine  high coloured, scanty, and
voided with a sense of scalding.   It is oc-
casionally dark coloured,  turbid, or even
bloody.  The face and eyes are suffused
and turgid; blood occasionally flows from
 the nose; the injection of the  capillaries
occasions  a preternatural  turgescence  of
the skin and  all the superficial vessels,
and the surface sometimes assumes a deep
 red, purplish, or mottled appearance.
   As the disease advances, the vital pow-
 ers are gradually exhausted under its ra-
 vages ; the coats of the inflamed arteries
 undergo important  alterations; the blood
 sometimes becomes coagulated in the af-
 fected vessels;  and with a general aggra-
 vation of most of the  above symptoms, a
new train of phenomena is frequently su-
peradded.  The general anxiety, restless-
ness,  and distress, now  increase.  The
pulse  augments in frequency; becomes
small, wiry, weak, irregular, and acquires
a  peculiar sharp thrill.  The dyspnoea is
more  distressing.  The heart is  affected
with frequent palpitations, and the slight-
est motion or exertion, or an  erect pos-
ture,  occasion vertigo or  a disposition to
syncope.  The tongue  is dry,  scabrous,
and covered  with  a  brown  sordes;  the
thirst is intense; the skin is covered with
clammy sweats; the countenance assumes
a sunken, decomposed or cadaverous ex-
pression, or it is lurid and cedematous; the
bodily powers decline, and the patient  is
affected with delirium, especially at night,
subsultus tendinum, or frequent convul-
sive movements of different  parts of the
body.  The bowels, which are at first con-
stipated, now assume  an opposite condi-
tion, and tlie dejections are frequent, dark
coloured, and highly offensive.  The urine
is  also dark, turbid,  and fcetid, and  the
whole of the secretions and excretions are
perverted.  The skin, which was  at first
simply injected, now assumes  a  deeper
purplish hue, and if the  inflammation oc-
cupy one of the principal arteries of the
extremities, the condition of the affected
parts undergoes important changes.  The
alterations  of the  textures of the vessel,
and the formation of fibrinous concretions
by the coagulation  of the blood  within,
gradually interrupt the transit of that fluid,
and the  portion of the member situated
below the seat of the disease, has its nu-
tritive functions impaired in a correspond-
ing degree.   The preternatural  pulsation,
which at first was  manifest along  the
whole course of the artery, is  now only
perceptible above the seat  of the disease,
while  below  it is  feeble and  indistinct.
This  arises from the gradual obliteration
of the vessel, and is attended with  a sense
of coldness and numbness of the part,  re-
sulting from the privation of its nutritive
fluid.   The obstacle to the course of the
blood  thus created, occasions a distension
of the artery above, with preternatural
pulsation; and Naumann remarks, that in
one case, it imparted the sensation, to the
finger, of a  distended  membranous  sac,
having a fluid issuing from its surface by
numerous pores.  (Handbuch   der Med.
Klinik. II. 606.)  Should the obliteration
be complete,  all pulsation below  ceases;
the limb becomes cedematous;  the blood
gradually accumulates in the radicles of
the veins,  giving rise  to  a dark ecchy-
mosed appearance, arranged either in iso-
lated  points,  or more diffused; the part
becomes cold and numb;  small purplish
phlyctenre make their appearance, and the
part finally falls into gangrene, unless the
collateral anastomoses  should  so far  es-
cape the disease, as to admit of their fur-
nishing a  sufficient  supply  of  the vital
fluid to obviate these consequences. With
the development of these phenomena, the
powers of life become more prostrated;
the pulse more frequent, small, sharp, and
irregular;  the clammy sweats more  pro-
fuse; the delirium gives place  to a  pro-
found coma; the evacuations come away
involuntarily; hiccup supervenes; the ex-
tremities grow cold, and the patient either
sinks exhausted, or death is ushered in by
convulsions.
   When the disease takes a more favour-
able course, it is represented by Puchelt,
that it sometimes pursues a regular pro-
gress until the seventh day,  exacerbating
twice  in the  twenty-four hours, and then
forms  a  crisis, either by a free perspira-
tion, hemorrhage,  or the deposit of a co- 
404              ARTERIES. (Inflammation, its Complications.)
pious sediment in the urine. (System der
Medicin. Band II. II. Th. 63.)
  Complications.  These may be regarded
as the ordinary phenomena of acute in-
flammation of the  arteries.  But in some
instances it presents complications which
deserve a passing notice.  Several condi-
tions have been spoken  of by authors,
either as accompaniments or consequences
of the disease, and it becomes an  impor-
tant question to decide, how far they can
be properly regarded as such.   Of these,
the following may be noticed :
  1.  Erysipelatous  inflammation  of the
arteries.   Whether  inflammation of the
arteries arising from common causes, and
independent of injury inflicted upon these
vessels, ever  assumes the  erysipelatous
character, we  have had no opportunity to
decide.  We  are convinced that such an
occurrence  must be rare,  since  it has
scarcely been  noticed by those  who  have
possessed the most extensive means of ob-
servation.  Still it would be improper from
this to infer its non-existence; for some ex-
amples, apparently well authenticated have
been reported, and  it perhaps would  be
oftener observed, but for the difficulty of
discriminating between it and simple in-
flammation, especially when the surround-
ing  parts do not become  extensively in-
volved in the disease.  Amongst other ex-
amples of idiopathic erysipelatous inflam-
mation of the  arteries, we  may refer to
one reported by Hankel, in which the as-
cending portion of the aorta and the arch
were involved to  a considerable extent.
(Rust's Magazin fur die Gesammte Heil-
kunde.  XXXIX. 234. 1833.)  The sub-
ject of the case was a stout man, aged 30,
descended of  parents who had  been sub-
ject  to gout  and  erysipelas.   The most
prominent symptoms during life were, ex-
treme difficulty of breathing, and agoniz-
ing pain beneath the sternum, which was
considered rheumatic.  Erysipelatous in-
flammation of the arteries following the
application  of ligatures  and other  inju-
ries is probably of less rare occurrence.
Guthrie  seems to think, that whenever
inflammation is excited by this cause, and
spreads along the internal coat of  an ar-
tery untd it reaches the heart it is of the
erysipelatous character, and is a most fatal
disease.   He  subjoins, that he had only
verified its existence by dissection in three
instances; and in all, the patients died
very quickly  after the accession  of the
symptoms; but that others  have noticed
in  their post-mortem examinations, in-
flammation extending from the spot where
a ligature had been applied, up  to the
heart, and in these cases, death was pre-
ceded by  symptoms of low  and irritable
fever. (Diseases and injuries of the arte-
ries, p. 20.)  In one of the three cases,
the subject of which died suddenly and
unexpectedly, the limb was greatly swell-
ed and gorged with blood; the femoral ar-
tery, when opened, appeared more vascu-
lar than is commonly observed; its inter-
nal membrane was  very red,  and easily
separated  from the middle coat,  and the
fluid which lubricated its surface was of a
more serous nature than usual, and greater
in quantity.   In each of the other cases,
the  right leg  and  thigh  were  greatly
swelled and cedematous; the skin Was of
a pale dead-white colour; the countenance
extremely  anxious  and   bedewed  with
sweat; the pulse 140 and weak, and the
patient sensible. The arteries showed the
same characters as  in the other, and the
disease extended upwards as high as the
diaphragm.' He represents, that the symp-
toms which  mark  this  state  of disease,
when distinguishable, are a very quick
pulse, a rapid deterioration of the state of
the patient, and degeneration  into irrita-
tive fever, with low delirium followed by
death.  (Ibid. p. 21.)
  How  far these  characters justify the
distinction attempted to be established, we
will not positively affirm.   In a case to
which we have alluded above, in which
death Was rapidly  induced  by  inflamma-
tion spreading along the  brachial artery
to the heart, from a ligature  which had
been applied  after amputation of the arm,
most of  the symptoms  enumerated by
Guthrie were present; yet it will be seen
that they are also contained in the cate-
gory of phenomena pertaining  to common
inflammation of the arteries.
  2.  Inflammatory and  Ataxic  Fever.
The hypothesis of the association of vio-
lent inflammatory  fevers with  inflamma-
tion of the arteries, was first promulgated
by  J. P.  Frank.   It afterwards gained
many advocates, and is still believed by
some respectable pathologists,  especially
in Germany.  Reil seems  to  think that
while inflammation is a local affection of
the vessels, inflammatory fever is a gene-
ral phlogosis of the tunics  of  the whole
vascular  system;   and  after  remarking,
that when violent fevers of this kind are
trusted to nature, they give rise to a gene-
ration of  purulent matter in the  arteries,
which,  if not too large  in quantity, is
thrown off by the ordinary emunctories,
as the kidneys, &c, he asks the question,
whether the  blood  is under such circum-
stances metamorphosed into pus, or that 
ARTERIES. (Inflammation, its Complications.)              405
matter is the product of the inflamed ves-
sels. (Ueber die Erkentniss und Cur der
Fieber. II. 305.)   Not to mention Pinel,
Joseph Frank, Hilpenbrand,  Raimann,
Wedekind, Berends, Puchelt, and many
others, who have  adopted similar, if not
identical views, we may remark,  that by
Bouillaup, inflammatory fever is declared
to be nothing more  than a general irrita-
tion of the sanguiferous system, which
does not differ from inflammation proper.
(Traite desfievres essentielles.  p.  19. Pa-
ris, 1826.)  In corroboration  of this opi-
nion, he represents that he found  redness
of the lining membrane of the heart ele-
ven, and  of the  vessels, eight times,  in
forty-nine  examinations  of persons dead
of fever.  Louis observed unusual  redness
of the lining membrane of the heart, three
times in fifty-four subjects, and the same
condition of the aorta in twenty cases out
of the same number;  but  Andral  only
found this redness  six times in eighty-six
fever subjects.
   It will thus be seen,  that evidences of
inflammation of the arteries in those who
have died of fever, is far from being con-
stant, and that the chief necropsic  char-
acter of this inflammation  discovered  in
the cases  alluded to was, a preternatural
redness of the lining  membrane of the
vascular system.   If then  we recall  to
mind the  remarks already made in refer-
ence to the nature of this redness, under
the head Aorta, and in the first part of the
present article, the inference  will be  irre-
sistible, that the anatomical characters of
fever do not support that hypothesis which
makes its essential character consist in a
state of inflammation of the sanguiferous
vessels in  general, and  of the arteries  in
particular.  The  arteries,  it  is true,  in
common  with the  other tissues of the
body, may become involved in inflamma-
tion in some cases of fever.  Yet such im-
plication seems rather to be an accidental
consequence of the preternatural stimula-
tion of"the vascular system, excited by the
affection of other organs, and by changes
taking place in the properties of the blood
during the progress of the disease, than a
primitive  and  necessary element of the
fever itself.  Hence, it is oftener observed
in fevers of a malignant or ataxic charac-
ter, than in those which are less protract-
ed, and  in which alterations  of the blood
are consequently less considerable.   The
deterioration of the blood, moreover, which
takes place in  malignant fevers, in small-
pox, scarlatina, &c., together with  the cor-
responding impairment of  the cohesive-
ness of the solids,  are precisely the condi-
tions  in which the red tinting of the ves-
sels from imbibition is most apt to occur.
Inasmuch, therefore, as it has been proved
satisfactorily, that in a large proportion of
cases, redness of the  lining membrane of
the heart and arteries is not inflammatory,
we should  be cautious  not to  attach too
much importance to  it, when we find  it
existing as a concomitant of fever, either
inflammatory or ataxic.  Nor does  the vio-
lent action of the heart and arteries—the
strong, full, and bounding  pulse,  and the
active commotion of the vascular  system,
which form such conspicuous phenomena
at the outset of these forms of fever, ne-
cessarily indicate that the arteries are in-
flamed.  They are inordinately stimulated
by the sympathetic influence transmitted
to them  from other organs similarly af-
fected—by the blood too richly charged
with fibrine, albumen, &c,  or by various
deteriorations developed in the properties
of that fluid, under the  influence of im-
paired or perverted innervation, by which
it acquires  properties detrimental to the
vessels which circulate it.  Thus far then,
the arteries are  involved in febrile affec-
tions: they feel  their influence  in  com-
mon with  other tissues and organs, but
there are no facts to justify the  inference
that any one of the various forms of fever
depends primarily and  essentially on in-
flammation  of these  vessels.   There  is
often a preternatural pulsation of the heart
and  arteries  observed  during  convales-
cence from protracted fevers, which has
by some  been regarded  as  an indication
of inflammation of the  lining membrane
of the vascular system.   We will not as-
sert  that  it may not sometimes  depend
upon  this cause; yet  in  a  majority of in-
stances, we are satisfied from  a close at-
tention to  the subject, that it is owing  to
a simple  state of neuropathy of the heart
and arteries, which, instead of being re-
lieved by antiphlogistics, is often  exaspe-
rated by such remedies.   It is analogous
to the condition produced  by  excessive
abstractions of blood, and  requires for its
removal  an  analogous  treatment.   We
have  within a few days effectually reliev-
ed an individual recovering from a pro-
tracted attack of fever, in whom this con-
dition of the vascular system existed to a
distressing degree, by large doses of car-
bonate of iron suspended in wine.
   It has been mentioned above, on the au-
thority of Reil, that  in the course of in-
flammatory fevers,   purulent  matter  is
generated  in  the blood-vessels, either by
changes  taking place in the blood itself,
or by a secretory process of the inflamed 
406              ARTERIES. (Inflammation, its Complications.)
coats of the arteries, and that the lateri-
tious  sediment found in the urine is com-
posed of this matter thrown off by the kid-
neys.  This  opinion is  also  adopted by
Langenbeck (Nosologic und Therapie der
Chirurgischen Krankheiten. I. 588.); and
Trevirakus suggests that the  crisis of
fevers is probably formed  by the genera-
tion of purulent matter in the  entire mass
of blood, which is so modified in the act
of being thrown  off by the emunctories,
that it cannot be recognized as such in
the secretions and excretions. (Biologie.
V. 417.) This hypothesis, if well founded,
would go to corroborate the doctrine that
many fevers and febrile affections are de-
pendent  on inflammation of the arteries.
But as the predicate is unfounded, the in-
ference cannot be valid.  There is in the
first place, no evidence of the generation
of purulent matter in the blood  as a com-
mon result and instead of the copious se-
diment thrown down by the  urine being
any proof of the fact,  it  can  be  easily
shown to be dependent on another condi-
tion.   It  is well known, that under any
preternatural excitation  of the  heart and
arteries continued for some time, the blood
becomes much richer in fibrine  and albu-
men than it is in health.   So  soon, there-
fore,  as the excessive action  is subdued,
or  in other words, the disease terminates
by crisis, these fibrinous and albuminous
materials  are reduced  to their natural
standard as regards  quantity; and the re-
dundancy of the latter being thrown off
by the secretions, it manifests itself in the
urine, in form  of a  copious lateritious se-
diment  which is composed  of albumen,
blended with various salts which pertain
to that fluid.
   3.  Spontaneous  gangrene.  We have
observed,  in  treating of  the anatomical
characters of acute arteritis, that when  it
attacks  the  vessels of the extremities,  it
very often terminates in gangrene.  From
this  circumstance,  it has been  alleged by
respectable pathologists, that  spontaneous
gangrene very  generally depends  upon
inflammation of the arteries, terminating
 in obliteration of  their  calibre,  and  a
 consequent  obstruction of the  course of
 the blood  through the limb.   When it  is
 proved  that  the  effects of inflammation
 are to occasion a deposition of  coagulable
 lymph by the  internal membrane, coagu-
 lation of the blood within,  and a conse-
 quent obliteration of the vessel, it follows
 of necessity, that  gangrene  must be the
 result  except the  collateral  circulation
 should be sufficient to compensate for the
 interruption of  the course  of  the blood
through the main arteries of the member.
In this  respect, therefore, it  must be ad-
mitted, that inflammation of the arteries
is a cause of gangrene—not directly, in
virtue of any peculiarity it may possess,
but indirectly, by cutting off the supply
of blood which is necessary for the nutri-
tion and preservation of the part.  Hence
the obstruction of the main vessels by
fibrinous concretions, which  is found un-
der such  circumstances,  is not a conse-
quence of the mortification, but the cause,
and these  concretions only produce their
effect like any other mechanical obstruc-
tion, as extensive ossification of these ves-
sels, and  various  other morbid products,
which are sometimes observed to occa-
sion results  precisely similar.  Arteritis
should not, therefore, be regarded as the
sole cause of spontaneous gangrene, but
only as one amongst many others, capable
of exercising a similar influence upon the
circulation of the part affected. (See Afor-
tification.)
   After all these remarks, it must be ap-
parent that  in the present state of our
knowledge it  is exceedingly difficult to
point out  any characters upon which a
certain reliance can be placed in forming
a diagnosis of acute arteritis.  When the
aorta and  other large arteries, which are
deep-seated,  are affected, the symptoms
which seem  to be entitled to most confi-
dence are, an augmented activity of the
pulsations of that vessel, and sometimes
of the whole arterial system; a sense of
heat, pain, or uneasiness,  following the
course of the affected vessel; a feeling of
great anxiety, and a disposition to syncope,
such as occurs in many affections of the
heart.  In the abdominal aorta, when this
preternatural pulsation and the other symp-
toms exist, if great tenderness should be
observed on  pressure, the reason for sus-
pecting inflammation wdl be still stronger.
If in addition to  these  indications, there
should be violent throbbing  of the whole
arterial system,  general turgescence of
the veins, together with great  injection
of the capillary vessels of the skin, there
will be a strong presumption of the exist-
ence of extensively diffused arteritis, pro-
 vided no  evidences of pericarditis, aneu-
 rism, or  hypertrophy of the left ventricle
of the  heart,  be  discovered.  When the
 inflammation affects a single vessel, and
 especially one that is superficial, it may
 generally be discovered by  the  following
 symptoms:—a sense of heat, tenderness,
 or pain, following the course of the ves-
 sel ;  a strong, peculiar, vibratory or purr-
 ing pulsation, more forcible  above than 
ARTERIES.  (Acute Inflammation, Causes.)
407
below; a sensible thickening, induration,
and enlargement of the vessel; and in the
last stage  of the disease, paleness, numb-
ness, and  coldness of the portion of the
member below the seat of the inflamma-
tion.  If,  at this juncture, the pulsation
should be  found strong  and purring above,
and feeble or entirely extinct below, with
an cedematous condition of the limb, ec-
chvmosis, phlyctense, or vesications of the
skin, manifesting a tendency to gangrene,
there can be little reason to doubt the na-
ture of the disease, and that it has already
occasioned obliteration of the vessels. Still,
it should be remarked,  that most of these
symptoms may be observed in other affec-
tions, and that great circumspection should
be observed in forming a conclusion from
any of them.
  The symptoms of chronic arteritis are
so diversified, according to the  changes of
structure  and capacity developed in  the
affected vessel, that  it would be needless
to attempt to enumerate them.  In  many
 cases, this form of the disease occasions
 very  little  functional  disturbance,  and
 when it has proceeded so far as to give
 rise to  extensive transformations of the
 coats of the vessels,  it generally becomes
 so  far blended with other diseases, as to
 render  it impossible  to discriminate be-
 tween them.
   Causes of  acute  inflammation of the
 arteries.  Acute arteritis may be produced
 by any  of the ordinary causes of inflam-
 mation.   Yet it is a remarkable fact that
 the whole of the surrounding parts some-
 times slough away, and leave  the arteries
 bare and exposed, without their coats par-
 ticipating in the disease.   They are like-
 wise found  traversing  gangrenous parts,
 large abscesses, masses of encephaloid or
 cancerous matter, and  parts which are in-
 tensely inflamed, preserving  the perfect
 integrity  of their structure throughout the
 whole progress of those  diseases.   This
 immunity, however,  does not always  ex-
 ist and they accordingly sometimes take
 on inflammation, either from  causes act-
 ing directly on them, or exercising their
 influence through the  general system. In
 regard  to sex as a predisposing  cause of
 the disease,  it has  been  observed,  that
 males are more liable to it than females.
 A  gouty and  rheumatic diathesis   has
 been supposed to predispose in a peculiar
 manner to  inflammation of the  arteries,
 and it has been observed,  that those who
 are remarkable for their liability to erysi-
 pelas, often  suffer from this  disease.  It
 may also be produced  by sudden  exposure
 to cold or wet when the body is  preter-
naturally heated, by violent passions  and
emotions of the  mind, inordinate bodily
fatigue  or exertion, a too free indulgence
in articles of diet  calculated to increase
the crasis  and stimulating properties of
the blood, the immoderate use of vinous
and  alcoholic potations—in  short,  what-
ever tends to keep up a preternatural ex-
citement of the heart and arteries. Hence,
as we  have  previously remarked,  it  is
sometimes a concomitant  of inflammatory
and  other fevera   Breschet  observed
several cases  in which it was excited by
erysipelas, and Copland  found the arte-
ries inflamed in two cases of puerperal
fever.   It may also  be induced by repelled
eruptions,  by the  absorption of purulent
or other irritating matters—the abuse of
mercury, protracted or badly-managed sy-
philis, the introduction of'poisons into the
circulation, or the excessive use of acid
drinks.  It is probable that when it takes
place in the advanced stage of malignant
or ataxic fever, the direct cause of its de-
velopment is the generation of some irri-
tating  property in  the blood, which exer-
cises a deleterious  influence upon the sur-
face of the vessels in contact with which
it circulates; and the same is doubtless
true in some of the more violent exanthe-
matous affections.  Other causes are purely
traumatic.  They  are, preternatural dis-
 tension or elongation of an artery,  as in
 dislocations; incised, punctured, contused,
 and lacerated wounds affecting these ves-
 sels; long-continued  pressure,  the  influ-
 ence of surgical operations, the  applica-
 tion of  cauteries,  and  the action  of
 ligatures when applied for the purpose of
 arresting hemorrhage or the cure of an-
 eurism.  Notwithstanding the  slight dis-
 position of the arteries to take on inflam-
 mation when tied, a character in which
 they differ remarkably from veins, the in-
 fluence of the ligature  upon them  is oc-
 casionally  productive of  serious conse-
 quences.  We have already alluded to a
 case in which violent inflammation of the
 brachial artery was  excited by a ligature
 applied after  amputation,  and occasioned
 death  by spreading to the heart and peri-
 cardium.  The arch of the aorta was  found
  intensely inflamed,  and  lined by a  pulpy
 pseudo-membrane; the pericardium filled
 with  a turbid sero-albuminous fluid, and
 the heart so softened that its texture could
  be  broken  up  under very slight  force.
  Hodgson reports  a  case in which inflam-
  mation extended  from the femoral artery
  to the heart, after  the application of a liga-
  ture to that vessel, and occasioned death:
  a  similar  occurrence was  observed by 
408
ARTERIES.  (Acute Inflammation, Treatment.)
Cline and Abernethy ; and Langenbeck
states,  that  in  one instance  in which he
amputated  the leg,  the  vessel  became
highly inflamed as high as Poupart's liga-
ment and was found filled with purulent
matter.  The same condition was observed
by Evans, in the axillary and brachial ar-
teries,  after the application of a ligature
to the carotid for the cure of an aneurism
of the innominata;  and Oehme  has  re-
ported a case,  in which the hypogastric
arteries were affected with inflammation
in consequence of the application of a liga-
ture to the umbilical chord.  Examples of
the transfer  of  inflammation from wounds
of the  neighbouring parts to the large ar-
teries are so common, that it is not neces-
sary to specify them.
  Treatment of acute inflammation of
the arteries.  Much need not be said on
the treatment  of acute inflammation of
the arteries. It must be varied according
to the stage of the disease,  its intensity,
and  the complications  with which  it is
associated.   In the active or sthenic forms
of the  disease, especially when the  arte-
rial  system  is  extensively involved, the
free abstraction of blood presents itself as
the chief remedy, and it must be pushed
to an extent commensurate with  the  exi-
gencies of the case, and the powers of the
system  to bear it.  Blood must be freely
abstracted from the arm, and the opera-
tion repeated as often as the necessity
may recur, provided circumstances should
not arise to render such copious depletion
improper.   Local depletion  will also be
found highly serviceable, especially when
the affected vessel is superficial.  Leeches
should be freely applied along the course
of the inflamed artery, and the  bleeding
encouraged  by  fomentations with warm
water.  Should one application not be suf-
ficient, they must be repeated at proper
intervals, until a sufficient effect is  pro-
duced.  It was remarked by Frank and
Spangenberg, that the abstraction of blood
rendered the pulse harder and more tense.
This has been regarded by  some practi-
tioners  as a sufficient reason for not re-
sorting to the practice.  But  when the in-
dications of active inflammation  are  une-
quivocal, bleeding is indispensable, and if
the disease  should be  associated with a
neuropathic disposition of the vessels, dis-
posing them after venesection to take on
this peculiar kind of reaction, when suffi-
cient blood has been detracted, it may be
useful, with the view to prevent the bad
effects  of this  nervous erethism, to  pre-
scribe an opiate, either alone,  or  what
will be preferable,  combined with  anti-
mony and  calomel, as recommended by
Copland.  But  in  resorting to  the  ab-
straction of blood,  it must be borne  in
mind, that  there are not unfrequently cir-
cumstances in the course of this disease,
which will render it unsafe to push gene-
ral bleeding to a great extent.  There is
frequently  much proneness to  syncope
even  after a slight bleeding, and the in-
flammation of the arteries is besides only
developed  in many instances,  during tlie
last stage  of inflammatory and ataxic fe-
vers,  small-pox,  scarlatina,  puerperal fe-
ver, &c, when the powers of life are  so
prostrated,  that the  withdrawal of even a
small quantity of the vital fluid might be
productive  of fatal  consequences.  Still,
when there  is  great  tenderness in the
course of an artery, especially if the ves-
sel be superficial, it may be necessary in
some instances,  even under these circum-
stances, to  apply a few leeches  along the
course of  the  vessel—acting  upon  the
same principles that guide us in the treat-
ment of other local  inflammations, attend-
ed with  impairment of the  vital  powers.
   Simultaneously with the abstraction of
blood, the patient should be put upon  the
use of mild saline cathartics, either alone
or alternated  with  calomel;—nitrate of
potash, antimonials, mild diluent, subacid
drinks, cathartic enemata, and, when pre-
ternatural  throbbings of the arteries and
palpitations of the heart follow the  ab-
straction of blood,  large doses of opium,
black drop, or hyoscyamus, may be  given
in combination with calomel and antimo-
ny, to which when the powers of life are
considerably prostrated,  camphor may be
added.  Mercury, pushed to the extent of
producing  slight soreness of the mouth,
has been recommended by Hope,  Berndt,
and Copland.   But from the tendency of
this  article to occasion preternatural ex-
citement of the heart  and arteries, when
administered so  as to produce its  constitu-
tional effects, we should be reluctant to
employ it in that manner, except in those
cases in which the arteritis is induced by
syphilis.   After sufficient depletion, Hii/-
denbrand  recommends the acetate of lead
and  digitalis, and from the power possess-
ed by both of these agents in moderating
the activity of  the circulation, we doubt
not they may be sometimes useful when
employed   with proper discrimination.
Neither of them should be relied on to
the  exclusion of more important means,
nor will they be proper in the  very  ad-
vanced stage of the disease when typhoid
symptoms  have made  their appearance.
Colchicum  has  also been  suggested by 
ARTERIES.  (Inflammation, Treatment.)
409
Copland ; and when the intensity of the
inflammation is considerably subdued, leav-
ing a preternatural throbbing of the  arte-
ries, which  is  dependent  on a state  of
morbid nervous erethism of those vessels,
prussic acid might  perhaps be employed
with advantage.
  When the. disease occupies a superficial
artery, as for example, in the extremities,
the neck, &c,  after  sufficient blood has
been  detracted by leeches, the part may
be constantly covered with refrigerant an-
odyne lotions, or if these should disagree,
tepid ablutions  may be employed with ad-
vantage.  In addition  to  these  applica-
tions, Berndt recommends, after  the  in-
flammation  has lost its active character,
the employment of warm moderately ex-
citing aromatic fomentations,  lotions of
muriate of ammonia dissolved in vinegar
and  water,  and frictions with mercurial
ointment.  (Rust's Handb.  der Chirurgie.
II. 298.)   Under the same  circumstances,
a blister applied over the part,  so effica-
cious in  some  cases of phlebitis, might
possibly produce a good effect Revulsives
will also be  useful in the advanced stages
of inflammation of the large  arteries of
the splanchnic cavities. (See Aorta.)
   The various  complications of the dis-
ease with the  several  forms of fever,—
with  erysipelas, gangrene, &c., must be
managed  upon the general principles pro-
per to be  observed in  the treatment of
those diseases.   As  these complications
are seldom observed, except when the vi-
tal powers have become considerably pros-
trated, blood-letting to any  considerable
extent will seldom be admissible,  and the
chief reliance must be placed  upon mild
antiphlogistics,  and  those  means which,
by exciting the  several emunctories to the
performance of their proper functions, will
tend to separate from  the mass of the cir-
culating fluids,  those  materials which are
generated in the blood, and tend  to irri-
tate the vessels.   When  obliteration of
the arteries has taken place, giving rise
to gangrene, the  case must  be managed
according  to the rules laid down in the
article Mortification.
  It is scarcely necessary  to subjoin, that
during the whole treatment, perfect qui-
etude of both body and mind should be
rigorously enjoined.   The  patient should
be strictly confined to a light farinaceous
diet with  iced,  or cool demulcent drinks;
and even during convalescence it will be
necessary  to restrict him from  all animal
food for a considerable time. Every source
of irritation, both physical  and  mental,
must, in short, be carefully avoided, since
   vol. n.          35
the heart and arteries are preternaturally
susceptible, and  owing to their intimate
sympathies with the  other organs, they
will be seriously influenced by an  active
impression  made upon any  part of the
system.
  The treatment of chronic inflammation
of the arteries may be dismissed in a few
words.  As the disturbance it occasions is
seldom observed until the  disease has ad-
vanced so far as to  occasion extensive
transformation of the arterial tissues, its
existence  is not known whde it is in a
condition to be cured.  When these trans-
formations of texture  have taken  place,
it  is  beyond the reach of our remedies,
and all that can be done is to obviate or
remove the inconveniences they may oc-
casion.   They are  chiefly such  as arise
from  impaired circulation, and when they
give rise  to congestions of the left side of
the heart or  of  other organs, these must
be removed by repeated small abstractions
of blood,  mild aperients,  a proper atten-
tion to diet, and an avoidance  of the ordi-
nary  sources  of irritation. In  some cases,
when there is a loss of tonicity,  unat-
tended with serious changes of structure,
chalybeates,  and other tonics,  with the
shower-bath, may be useful.

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   *> 2.  Dilatation of the arteries.  (Arle-
riecktasis, Angiectasis,  Telangiectasis.)
In  consequence  of  the almost  incessant
distending influence to which  the arteries
are exposed in  the  performance of their
office, they often become preternaturally
dilated, either  at one or more points of
limited extent,  or throughout  a  consider-
able portion  of their distribution.  This
dilatation assumes different forms accord-
ing to the extent of the vessel affected,
and  the degree  of the  distension.   It is
also varied in its appearance  by the  size
of the artery involved, and sometimes pre-
sents a different aspect when it affects the
arterial ramifications and their anastomos-
ing branches, from that  which it exhibits
in  the  primitive and  secondary  trunks.
All  these modifications, however, what-
ever their situation and extent, may be re-
duced  to five primitive  forms.  Four of
these have been enumerated by Breschet,
as follows: 
ARTERIES.  (Dilatation.)                         4H
   1. True sacciform aneurism (aneurisma
 vera sacciforme);
   2. True  fusiform aneurism (aneurisma
 vera fusiforme);
   3. True cylindroid aneurism (aneurisma
 vera cylindroideum); which he subdivides
 according as it affects the large arteries,
 or  their small  ramifications,—including
 under the  latter  the  aneurism by anasto-
 mosis of John Bell,  or the erectile tu-
 mours of Dupuytren.
   4. Cyrsoid aneurism (aneurisma cyrsoi-
 deum),  arterial varix (varix  arterialis)
 of Dupuytren.  (Memoires chirurgicaux
 sur differentes especes d'Anevrismes; par
 G.  Breschet. p. 12.  Paris, 1834.)
   This  arrangement we shall adopt, with
 the following modifications.  We shall re-
 ject the term aneurism, as not being ap-
 plicable to the modification of the arteries
 which we wish to consider, and substitute
 the word dilatation.  And the  third vari-
 ety we shall divide into two,—the first in-
 cluding the proper cylindroid dilatation of
 the larger arteries, while  under  the sec-
 ond we shall include,  as a separate divi-
 sion, the pathological state of the minute
 vessels, described by John Bell under the
 appellation of aneurism by anastomosis,—
 and denominated  erectile  tumour by Du-
 puytren, hsamatonca by Alibert, and te-
 langiecktasy by Von Graefe.
   Scarpa was the first to expose the im-
 propriety of applying the  term aneurism
 to a simple dilatation of the arteries; but
 he was not justified in asserting, that in all
 cases of that disease, there is  a solution
 of continuity of one or more of the coats
 of the vessel.  He affirmed, that the con-
 dition usually denominated true aneurism
 never exists, and that  although the  coats
 of an artery may be dilated, so as to form
 a tumour of  considerable magnitude,  it
 never exhibits the characters proper to an
 aneurismal tumour.  Subsequent observa-
 tions have clearly proved  that this asser-
 tion is too exclusive. A considerable  num-
 ber  of well authenticated examples of an-
 eurism formed by the dilatation of all the
 coats of an  artery, and having the  ordi-
 nary lamellated fibrinous concretions  with-
 in, have been reported; and although sim-
 ple dilatation is  much more common, the
 doctrine of Scarpa relative to this point,
 cannot be sustained.  These  considera-
 tions have led to attempts  to draw a line
 of distinction between the characters of
 the condition properly denominated true
 aneurism, and that in which the coats of
 an artery are simply dilated, without pre-
senting any of the other phenomena pecu-
liar to aneurismal tumours.  In  simple di-
 latation, there are no fibrinous concretions
 formed within the vessel.  The blood con-
 tinues to circulate in immediate contact
 with the lining  membrane, there being nt
 obstacle to its course, except so far as it
 may be  impeded by the increased calibre
 of the artery.   In true aneurism, on the
 contrary, the whole internal surface  of
 the  dilated vessel is lined with fibrinous
 concretions, variable as to their consist-
 ence,  disposed  in a  concentric series  of
 layers, the most external of which adheres
 to the internal surface of the  artery.  (See
 Aneurism.)  It should be remarked, never-
 theless, that in some cases of great dilata-
 tion, small cracks and fissures occasionally
 form in the lining membrane, which en-
 tangle the  blood, and occasion the devel-
 opment  of a thin soft layer of coagulum,
 or the  same effect  may  be produced  by
 the  roughness  of that tunic occasioned
 by  inflammation, or by  the  formation
 of albuminous deposits upon  the  inner
 surface  of  the  diseased  artery.   These
 concretions, however, are seldom  very
 considerable, except when the coats of the
 vessel are  extensively ulcerated or  ossi-
 fied : they but rarely exhibit  a lamellated
 arrangement, and  as Guthrie has cor-
 rectly remarked, they have more the ap-
 pearance of accidental irregular forma-
 tions, than of deposits in concentric layers.
  1. Sacciform dilatation.  In this  vari-
 ety of the disease, some portion of the cir-
 cumference of  the  artery, generally  of
 small extent, exhibits a small  sac-like pro-
jection, formed by the dilatation of all the
 tunics.   The size of these  sac-like expan-
 sions varies, some of them not  being larger
 than a pea, while others equal the volume
 of a half section of an egg divided longi-
 tudinally.  In the inceptive stage of their
 formation,  they are  so slightly elevated
 above the level of the adjacent portion  of
 the vessel  as to be  scarcely  perceptible,
 and frequently they are not more conspi-
 cuous  than the  slight bulgings denomi-
 nated sinuses of the aorta, which exist as
 a natural condition at the root of that ves-
 sel.  When they attain a greater size,
 they form considerable prominences stand-
 ing off from one side of the  vessel; and
 in a  few instances, we have seen several
of them  occupying different  portions of
the aorta, and giving it an irregular ap-
pearance.  The  dilated tunics of the ar-
tery  are  sometimes attenuated,  but occa-
sionally the fibrous and cellular coats be-
come hypertrophied  in proportion as the
expansion takes place.   Inasmuch, how-
ever, as these structures are less extensi-
ble than the cellular coat, they are not 
412
ARTERIES.  (Dilatation.)
susceptible of a very great degree of di-
latation, but are apt to yield under the in-
fluence of the distending force  to which
they are exposed, and thus lay the founda-
tion of aneurism.  This, indeed, is the na-
tural tendency of all extraordinary dilata-
tions  of the  arteries.   The causes which
give rise to this condition, are apt to occa-
sion more or less fragility of tissue, or pro-
duce  cracks, ulcerations, atheromatous or
calcareous deposits, which,  when the dis-
tension has reached a certain point, de-
stroy  the lining membrane, and  give ori-
gin to an aneurism, the progress  of which
is retarded at first by  the fibrous  coat.
These  changes take place as well when
the sacciform  dilatation exists alone,  as
when  it is associated  with the  fusiform
and  cylindroid varieties of the  disease.
Indeed it frequently happens, that a por-
tion of the ascending aorta is affected with
fusiform dilatation to  a considerable ex-
tent, and retains that character  until the
distension  has reached a  certain point,
when, owing to the causes mentioned, a
particular  point  of the  vessel  becomes
weaker than the rest, the  tunics in that
situation take on the sacciform dilatation,
and the lining membrane either  remains,
or is destroyed,—the bottom of the cavity in
this latter case being formed by the fibrous
coat.   An  instance of this kind  has  been
delineated  by  Meckel.  The ascending
portion, and  the arch  of tlie  aorta,  pre-
sented  a very large fusiform dilatation,
and appended  to this,  a little above the
origin of the vessel, there was a small sac-
like  projection, in  the  bottom of which
the lining membrane was destroyed, leav-
ing the fibrous coat entire. (Tab. Anat.
Path.  Fasc. II. tab. xv. Lips. 1820.)  In
such  instances,  should the disease  ad-
vance, the  fibrous tunic finally gives  way,
the cellular coat becomes greatly distend-
ed, and the disease assumes all the char-
acters of aneurism.
   Sacciform  dilatation occurs most fre-
quently in the ascending and thoracic por-
tions, and the arch  of the aorta.   It  may
take place, however, in the carotids, the
subclavian, the iliacs,  or the larger  arte-
ries of the extremities.  In some rare in-
stances, indeed, it occupies  all the princi-
pal arteries of the body.   A very inter-
esting example of this kind has  been re-
ported by Jules Cloquet.  (Surgical Pa-
thology. Translated by J. W. Garlick and
W. C. Copperthwaite. 105 PI.  II.  Lon-
don, 1832.)   The  whole of the arteries
were   covered  with aneurismal  tumours
(dilatations), varying in size from a hemp-
seed,  to a  large pea.   Some were found
upon the aorta, and its principal divisions;
but these were less prominent and fewer
in number than those upon the arteries of
the extremities.   The axillary, brachial,
radial, cubital, femoral, popliteal, tibial,
and  peroneal arteries,  formed,  in many
parts of their extent, strings of knots, so
numerous and closely situated were these
tumours: those of the lower extremities,
perhaps the  least numerous, might with-
out exaggeration  be estimated at several
hundreds. The arterial coats, of a whitish
colour,  did   not  appear altered  in their
structure, except  in the situation of the
tumours,  where  they were dilated  and
thin.   In none of these tumours was any
rupture of the internal or middle coat ob-
served ; nor  in  any  of the arteries,  was
there ossification or steatomatous degene-
rescence. The dilatations were also found
upon the small arteries, but not so distinct
as upon the larger.  Analogous  to this is
a  case observed by Pelletan, who found
sixty-three aneurisms (dilatations?) in the
arterial system of one  individual.  The
tumours varied in size from a filbert to an
egg. (Clinique Chirurgicale. II.  1.)
   2. Fusiform dilatation.  This is by far
the most common variety of dilatation. It
occupies the whole circumference of the
artery, while in the preceding form of the
disease,  the  chief distension takes place
on one side.  In this species of dilatation,
the portion  of the vessel which presents
the maximum of distension occupies the
centre of the  tumour, whence it tapers
gradually above and  below, until  it lose*
itself in the  natural calibre of the artery.
A greater extent  of the vessel is always
affected in this, than in the preceding va-
riety of the disease, and owing to the ter-
mination in the healthy portion of the ar-
tery being less abrupt, the dilatation may
attain  a  great magnitude without  the
formation within  its cavity of any lamel-
lated coagula.  The  tunics of the artery
are generally very much thickened, owing
to modifications of nutrition taking place
during the process of dilatation, and when
it  gives rise  to aneurism, or to the forma-
tion of lamellated concretions, it is gene-
rally owing either to a destruction of the
internal  and middle coat at  some point
weaker than  the rest, to the formation of
cracks and  fissures in the lining mem-
brane, or the coexistence of atheromatous
or calcareous deposits.
   Fusiform dilatation may take  place in
any of the arteries, but  it is  much more
common in  the aorta, and especially its
ascending portion, than in any of the pri-
mary, secondary, or ternary divisions.  We 
                           ARTERIES.

have already adduced numerous examples
of this species of dilatation of the aorta,
in treating of the pathology of that ves-
sel, and we may now remark, that in the
valuable cabinet of the University of Ma-
ryland, which contains the rich collection
formerly belonging to Allen Burns, there
are a number of specimens representing
this  dilatation  in all  the intermediate
grades between  its first inception, and its
termination in aneurism.  In one of them,
the coats  of the arch of the vessel are so
much hypertrophied, as to measure nearly
a. quarter  of an inch  in thickness.  In the
same collection  there is also an example
of fusiform dilatation of the femoral ar-
tery,  directly  beneath  Poupart's liga-
ment  Breschet  has figured a case in
which the portion of the internal carotid,
which is lodged in the  cavernous sinus,
was affected with this condition: also one,
having, besides a large fusiform dilatation
of the ascending aorta,  several of small
size  occupying the common and external
iliac arteries. (Op. Cit. PI. III.  p. 25.)
   3. Cylindroid dilatation.  In  this va-
riety of the disease, the dilatation not only
occupies the entire circumference of the
vessel, but also reaches along it to the ex-
tent of several inches, or even to a greater
distance.  In this  latter  particular it dif-
fers from the fusiform dilatation.  The ar-
tery is very greatly  augmented  in size,
but still retains its  cylindrical form, ex-
cept in the vicinity of the  point at which
the dilatation terminates, where it tapers
gradually, until the distended portion loses
itself in the natural calibre of the vessel.
The coats are generally very much atten-
uated, so  that if the dilatation be consi-
derable, the vessel is flaccid and collapses
like a vein. In some instances, neverthe-
less, there is more or less thickening,  es-
pecially at some points; but this condi-
tion is  less frequently observed  in this,
than  in the cirsoid  dilatation.  It is  be-
sides  not  unusual  for the vessel to be un-
equally distended at  different points, and
to present an irregular surface.   These
inequalities may indeed  be so great, as to
give  rise  to an association of the sacci-
form  with the  cylindroid  dilatation.   At
the same time that the artery is increased
in diameter, it often  becomes more or less
elongated; but this  seldom takes  place to
so great an extent,  as to occasion those
sudden and nodulated flexures which ex-
ist in arteries affected with varix.  A case
has been reported by  W. Hunter, in which
the thoracic aorta was enormously dilated,
and at the same time so much elongated,
that it fonned  numerous flexures between
                35*
(Dilatation.)                        413

the summit  of the chest and where it
glides  between the  pillars of  the dia-
phragm  (Med.  Observations and Inqui-
ries. I. 323); and Bertin and  Bouillaud
assert, that this vessel is occasionally so
much altered in size  and configuration as
to resemble the colon.  Dilatation of the
pulmonary artery is  rare;  yet Lobstein
has reported  the  case of an  individual,
aged thirty-four, affected with dropsy of
the pericardium, in whom this vessel mea-
sured two inches  in diameter, and  the
branches,  as far as  their  second divi-
sions, presented a proportionate dilatation.
(Traite d'Anat. Path. II. 534.)
   This form of dilatation is not, however,
confined to the aorta: it may affect any
part or even the whole  of the principal
arteries  or  their  larger   ramifications.
Breschet, indeed,  has  included  under
this head, aneurism  by anastomosis;  but
we prefer to consider that condition as
constituting  a distinct variety of dilata-
tion.  We had under our care a few years
ago, an  individual aged about fifty, who
after suffering for a long  time from  re-
peated  and  violent  attacks  of vertigo,
which could only be  relieved by small ab-
stractions  of blood, became dropsical, and
finally died of great prostration.   Nearly
the whole of the arteries,  from the aorta
even to the small ramifications, were found
dilated to at  least twice their natural size,
and many of them  in a still  greater  de-
gree.  The  superficial temporal branches
were almost as .large as the  brachial ar-
tery of a healthy subject and were so tor-
tuous, that they almost assumed a proper
varicose  condition.  The  dilatation  was
also very  great in the principal arteries
of the brain; and Breschet remarks that
he had  several times  encountered  this
condition in  the basilar artery, in the  ca-
rotid where it is embedded in the cavernous
sinus, the occipital, temporal, auricular,
the posterior tibial, and other arteries of
the upper and lower extremities, and in
those  of the splanchnic  cavities.
   So far as  the arterial ramifications  are
 concerned, some of them  are  liable,  at
 particular periods  of life, to a certain de-
 gree of dilatation which is entirely phy-
 siological.  This  takes  place  in the  ute-
 rine  arteries  during gestation,  and  the
 same thing is observed  in  many other or-
 gans when  their  activity is  greatly in-
 creased.  A temporary dilatation also takes
 place in all preternatural congestions; but
 these subjects do not properly fall within
 the scope of our present observations.  The
 physiological dilatations, however, which
 are developed  in  the collateral  branches 
414
ARTERIES.  (Dilatation.)
after  the obliteration  of the main artery
of a part niay be adverted to, and we may
besides remark, that it frequently happens
when the principal vessel  leading  to an
organ is obstructed, or narrowed, from any
cause, the others become preternaturally
dilated, to compensate for the defect.  An
interesting example of this kind has been
reported by  Jacobson, in which, the pul-
monary artery being exceedingly narrow-
ed,  the  bronchial  arteries  presented an
extraordinary degree of development
  4. Cirsoid dilatation.  This  is a proper
varicose condition  of the arteries, and is
identical in its  general  appearance with
the same form of dilatation of the veins.
Though long since  noticed by Vidus Vi-
dius,  it has  been but seldom alluded to by
pathologists. Dupuytren applied to  it the
appellation  of arterial varix,  and Bres-
chet, to whom we are indebted for the
first satisfactory exposition  of  its charac-
ters, has called it cirsoid aneurism. It con-
sists in  a dilatation of one or more arte-
ries, generally those of medium size, oc-
cupying a  considerable  portion of the
length of the vessel, which is at the same
time so  much elongated, that it is folded
and convoluted upon itself,  precisely like
a varicose vein.  At the points of  many
of the principal flexures, the dilatation is
often  greater than  in the  intervals, and
occasions rounded  prominences of consi-
derable size, which give the vessel  an ir-
regular knotted character.   The coats of
the vessels  are  generally attenuated and
flaccid,  and collapse when divided; but
occasionally they are considerably thick-
ened at some points, and are much harder
and more rigid than natural.   When su-
perficial, these dilatations can be felt
through the skin,  presenting the charac-
ter of uneven, convoluted, pulsating chords,
and if the integuments are thin, the bright
red colour of the  arterial  blood may be
distinguished through the  parts covering
the dilated  vessel.   The varicose  condi-
tion is  indeed  sometimes  so  great, as
to  form considerable pulsating tumours
of variable extent along the course of the
vessel, which may be partially emptied by
compressing the artery above,  so as to in-
terrupt  the  passage of the blood.
  According  to Breschet, the arteries
most liable to this variety of dilatation are
the iliacs, carotids, brachial, femoral, ti-
bial, occipital, auricular, radial, ulnar, the
palmar  and  plantar arches, and the oph-
thalmic  artery.  He quotes from Vidus
Vidius (De  curatione generative. II. 510.)
the case of  a Florentine citizen, the arte-
ries of whose head,  from the vertex to the
occiput, were so greatly dilated, that they
resembled immense varices, and pulsated
violently when touched.  He has besides
reported four cases, which he had himself
observed, with delineations of the appear-
ances presented by the parts.   In  all of
them the vessels were preternaturally di-
lated, and exhibited the convoluted knotty
arrangement of varicose veins.  In  the
first, the dilatation affected the radial and
ulnar arteries,  and especially the vessels
of the palm of the hand, which were roll-
ed up into  a convoluted mass, not unlike
an aneurism by anastomosis.  In the  sec-
ond, the tibial, peroneal, and tarsal arte-
ries were  involved, and the popliteal  was
affected with aneurism.  In the third, the
disease  occupied nearly the whole of the
ramifications of the temporal and occipital
arteries; but the posterior tibial and pero-
neal were also affected.  The whole arte-
rial system, besides, seemed to be involved
in this  tendency, and the tunics of the
vessels were so attenuated, that they col-
lapsed like veins.   In the fourth case, the
affection was seated chiefly in the ramifi-
cations  of  the occipital artery, and gave
rise to a morbid condition of all the adja-
cent portions of the head and neck.  Be-
sides  these, a  very interesting case has
been  reported by Jules Cloquet.  The
common,  internal,  and  external  iliacs,
were of a  remarkable size, and exhibited
numerous  tortuosities, which gave them
much the appearance  of the convolutions
of the small intestines.  The left iliac ar-
tery was much larger than the aorta, and
the parietes of all of them were soft,  flac-
cid,  and collapsed,  except  in  particular
parts.   They were besides unequally di-
lated at different points, and presented the
irregular nodosities common to varicose
veins. (Surgical Pathology,  p. 113.   PI.
HI. fig. 1.)
  5. Aneurism  by anastomosis. (Telan-
giecktasy.)  This form of dilatation is  con-
fined chiefly to the terminal ramifications
of the  arteries and  the radicles  of the
veins, and the principal difference between
it and the  preceding variety consists in
the fact, that the latter occupies branches
of larger size.  It sometimes gives rise to
a reddish,  or purplish pulsating tumour,
composed  of an intricate plexus of anas-
tomosing vessels, but  very often consists
merely of an intense suffusion of the  skin
of the same colour, no tumour being per-
ceptible.  As this condition of the vessels
will be particularly described in the  arti-
cle Navi materni, we shall not notice it*
characters further in this place.
  In nearly all cases in which the arteries 
ARTERIES.  (Dilatation, its Causes and Diagnosis.)
415
are dilated, they are found to have lost
their elasticity, especially when the aug-
mentation of the calibre  of the vessel is
considerable.  In general, all the tunics
can be distinctly recognized, but they are
almost always altered m their texture.  In
some cases they are very much thickened
—in others attenuated;  and  both these
conditions  may alternate with each other
in the same vessel.   In many instances,
however, when the arteries are very much
enlarged, the walls seem to be attenuated,
and collapse when separated from their
attachments with the surrounding parts,
although they  may be absolutely thicker
than natural.   This  appearance is owing
to the increased capacity of the  vessel,
which, when examined  in relation to the
thickness of its tunics,  makes  the latter
seem thinner than they are in health.  The
coats of the vessel are besides often ren-
dered preternaturally friable;—the lining
membrane  is often traversed by cracks or
fissures, and atheromatous and calcareous
deposits frequently take place, which so
far enfeeble the  tissues,  that  they  may
eventually give way, and lead to the trans-
formation of a simple dilatation into aneu-
rism or laceration of the vessel.  Owing
to the alterations of the  lining membrane,
and other arterial tunics, albuminous de-
posits  and  pseudo-membranes  are occa-
sionally formed upon the inner surface of
the vessel,  or  loose fibrinous masses are
developed by the coagulation of the blood,
which impede the circulation through the
part, and sometimes occasion complete ob-
literation.
   The causes  capable  of giving  rise to
dilatation of the arteries are  exceedingly
variable, but may all be  reduced  to  two
heads, according as they impair the capa-
bility of the vessels to resist the distend-
ing influence of the blood, or augment the
force with  which that fluid is circulated.
Amongst the  first may  be  enumerated
inflammation,   both  acute and  chronic,
and several of its consequences;  violent
stretching of the arteries;  contusions; car-
tilaginous,  osseous, and  other transforma-
tions of their  tunics; atheromatous depo-
sits; softening; the  changes produced in
the texture of these vessels by gout, scro-
fula, syphilis, and various other diseases.
Some have supposed that  the fibrous coat
of an artery is susceptible of experiencing
a  kind of  paralysis,  analogous to  what
takes place in muscular fibre, and  that di-
latation may arise from  this cause.  How-
ever this may be, there is abundant evi-
dence  to show, that when the powers of
the system are greatly enfeebled, a laxity
of the animal solids is generated, render-
ing them less  capable  than in health  to
resist those forces which are constantly
acting on  them.   When any of  these
causes have  predisposed  the  arteries  to
dilatation, that  condition  may be  induced
under the natural  impulse of the circula-
tion, independently of the co-operation  of
any other agency; but it will be doubly
apt to occur, if, with a predisposition  al-
ready formed, the  force of the circulation
should be preternaturally  increased, either
by the inordinate use of stimulating drinka
or articles of diet immoderate  exercise,
violent mental emotions, hypertrophy  of
the heart, or a mechanical obstruction to
the free  circulation of the blood through
an artery.   In this manner, dilatation of
the arteries of  many organs is induced  by
diseases  involving their  substance, and
when the arterial ramifications of any of
the tissues are predisposed to take on this
condition, they seem to possess the faculty
of inviting to the  part such  an increased
flow of blood,  as  to occasion a  preterna-
tural distension of their  tunics, precisely
as the inordinate stimulation  of an  organ
is capable of producing an inordinate con-
gestion of its  vessels.  Dilatation of the
arteries  may likewise  be produced by a
long-continued general plethora, and  its
development takes place  in some portions
of these vessels much more readily than
in others.  Wherever they form consider-
able  curves against which the column of
blood must impinge,—as the arch of the
aorta, &c.—at the angles formed by their
divisions, when they are superficial and
but slightly protected by surrounding struc-
tures, and  when  they  are liable  to  be
thrown out of  the direction of a right line
by the mobility of the adjacent parts, they
are most prone to undergo this alteration
of capacity. In many such situations, they
are not only acted on by  the force of late-
ral distension,  but the column of blood  be-
ing  constantly driven with great  force
against their flexures and curves, and  the
projecting angles which correspond to  the
points of their bifurcation, it  tends to oc-
casion an elongation of the tube, which in
proportion as it increases, necessarily gives
to it a tortuous arrangement sucn as is
observed in the cirsoid dilatation described
above.
   The symptoms and diagnosis of dilata-
 tion  of the arteries vary according to  the
 vessels affected.  When  the disease occu-
 pies  the aorta, it is often difficult to dis-
 tinguish it from aneurism of that vessel,
 as it is often attended with the same em-
 barrassment of the circulation, palpita- 
418
ARTERIES.  (Dilatation, ils Treatment.)
tions  of the heart,  sense of suffocation,
and difficulty of deglutition, from  its en-
croachment upon the surrounding parts.
There is also  frequently a  preternatural
small ness of the pulse, and it is remarked
by Hodgson, that the individual finds him-
self most comfortable on the left side, be-
cause in that position, the blood enters the
orifice of the aorta with the greatest fa-
cility.  When the dilated vessels  are su-
perficial, the disease can be  generally dis-
tinguished  by  the feel,  the artery being
hard and tortuous like a varicose vein, but
differing from it by  its pulsation.   Should
several arterial  ramifications  be  greatly
dilated, they often present themselves in
form of an irregular pulsating tumour, ex-
hibiting a knotty convoluted appearance,
and a deep red or purple suffusion. A di-
lated state of  the vessels of the  several
organs  occasions  various disturbances of
function, which, as  they may be produced
by other causes, cannot be relied on as in-
dications of the  existence of that condi-
tion.   Thus, an affection of this kind im-
plicating the arteries of the brain, may
give  rise  to head-ache, vertigo,  convul-
sions, or even apoplexy;  and  a  similar
state of the vessels of other organs, may
occasion pain,  and various diseased mani-
festations which it  is needless to  enume-
rate,  since it is not possible to trace them
to this cause during life.
   It will not be necessary to say much of
the treatment of this pathological  state of
the arteries.   It  is unfortunately  seldom
curable, and all that can be done is, to pal-
liate  the disturbance occasioned by it, and
to obviate, as  far as possible, its tendency
to  terminate in  aneurism, or to  destroy
life either by giving rise to mortal conges-
tions of important  organs,  or by  rupture
of some  of the diseased vessels, which
would often be productive of fatal hemor-
rhage.  As a general  rule, the same treat-
ment will be  indicated as  for  aneurism,
and this will be more particularly the case
when considerable dilatation affects  the
aorta, giving  rise  to serious disturbance
of circulation  and  respiration.  The diet
of the  patient should be regulated with
care, and while it is sufficiently nutritious
to obviate any considerable impairment of
strength,  all stimulating  articles of both
 food and drink should be prohibited.  Vio-
 lent exercise, and all active emotions of
 the mind,  should also be avoided.   When
 the disease is troublesome, tranquillity  is
 indispensably  necessary,  and it must be
 secured as well by  an avoidance of all
 causes of irritation, as  by a reduction of
 any preternatural excitement that may be
at any time induced.  Should congestions
of the left side of the heart be developed
by the obstacle to the passage of the blood
through the aorta, they must be cautiously
removed  by 6mall abstractions of blood,
repeated  from time  to  time as occasion
may indicate.  An over-distension of the
vessels of the different organs must be
treated in a similar manner.  Mild saline
aperients, cool refreshing drinks, digitalis,
anodynes  to  allay preternatural  nervous
erethism,  acetate  of lead,  prussic acid,
&c, may all  be  employed with more or
less prospect of advantage, under particu-
lar circumstances.   Care  must be taken,
however,  not  to  push the antiphlogistic
remedies too far.  It should be borne in
mind that whatever tends to impair the
powers of life, will enfeeble the tonicity
of the vessels, and thereby rather increase
than diminish the dilatation.  The object
of the remedies just  enumerated is to
overcome the tension of the vessels and
to  moderate  the  impulse of the heart,
without   enfeebling  the  energies of the
system.   It will indeed often be proper to
sustain the latter in some cases, especially
when it can be done without occasioning
any acceleration of the action of the heart
and arteries.  With this  view, and also
with  the  object of increasing  the cohe-
siveness of the tissues, various tonics and
astringents have been recommended. The
best will be the preparations of iron and
zinc, sulphate of alumine, the vegetable
bitters;  and when the affected vessels are
superficial, the application of slightly ex-
citing and active astringent epithegms to
the part;  as  lotions of alum, muriate of
ammonia, acetate of lead, a strong decoc-
tion  of  galls  or  oak bark, and  in  some
cases even ice or snow.  Under the same
circumstances, if the diseased  vessels oc-
cupy the superficies of the head or one of
the extremities, pressure, maintained by
a roller  bandage  properly adjusted, will
often  prove serviceable, by furnishing an
equable  support  to  the dilated  arteries,
and  preventing the increase of the dis-
ease.  When the morbid  condition of the
vessels  occasions  a varicose or vascular
tumour  upon the  head, it has been pro-
 posed to cut off the supply of blood by the
application of a ligature  to the common
 carotid artery, and  if this should fail, ow-
 ing to the free anastomosis, it has even
 been  suggested to tie both carotids, leav-
 ing only the vertebrals to supply the brain
 and parts about the head.   A similar ope-
 ration has been successfully performed for
 aneurism by anastomosis, and it might pos-
 sibly succeed  in cases of extreme  cirsoid 
ARTERIES.  (Obstruction and Obliteration.)               417
 dilatation of the superficial arteries of the
 head and neck.  The main artery might,
 on the same principles, be  secured, when
 the disease  affects the extremities,  and
 proceeds so  far as to render such a step
 necessary as a dernier resort.  It must be
 very rare, however, that an operation can
 be admissible in any variety of the  dis-
 ease,  and the  practitioner will  be com-
 pelled  to content  himself with palliating
 unpleasant symptoms, so far as he may be
 able, trusting the  issue  to  time, and  the
 powers of nature.
   Bibliography. —See Aneurism; and Aorta,
 Aneurism of.
   Besides ihe  authorities there designated, the
 following may be referred to:
   Graefe, (C. F. Von.) Angiecktasie, ein Bei-
 trage zur ratioUen Kur und Erkenntniss der Ge-
 fassausdehnungen. Leipz. 1804.
   Hodgson.  Traiti des maladies des arteres et
 des veines. Traduit par Breschet. I. 52.  Pa-
 ris, 1819.
   Sommer. Art. Angiecktasie. Encyclopaedisches
 Worterbuch.  Berlin,  1828.
   Naumann.  Handbuch der Med. Klinik.   II.
 296. Berlin, 1830.
   Hirschberg.   Diss, de telangiecktasi.  Ros-
 toch, 1832.
   Berard.  Diet de Med. IV. 113. Paris, 1833.
   Most.  Art. Angiecktasis, and  Art. Telangieck-
 tasis.  Encyklopadie der gesammten Med. und
 Chirurgisch. Praxis. I. 39., and II. 584.  Leipz.
 1833-34.
   Breschet.  Mimoires Chirurgicaux sur diffi-
 rentes isptces dAnivrismes.  Paris, 1834.

   ' 3.  Narrowing, obstruction, and oblite-
 ration of the arteries. The arteries, under
 various circumstances, as well congenital
 as acquired, are liable to have their cali-
 bre narrowed,  obstructed, or obliterated.
 This condition, so far as the aorta is con-
 cerned,  has been already considered  in
 the article in which we have  treated of
 the pathology of that vessel.   We there
 referred to all the  cases of constriction
 and obliteration of the aorta which had
 been at that time published.   But another
 instance, in which  the abdominal portion
 of that  vessel was  obliterated, has been
 recently published  by Louis, which  we
 may refer to in this place.  It occurred in
 an individual who died at La Pitie, of pul-
 monary disease.  Notwithstanding the ves-
 sel was closed, the collateral vessels were
 not developed in a remarkable degree, nor
 was any defect of  temperature observed
 in the lower limbs,  although the femoral
artery was also obliterated to a considera-
ble extent.  A very interesting  case of
narrowing of the abdominal aorta has been
reported by Jules Cloquet.  The subject
of it was a rickety child, which laboured
under deformity of  the spine.  The aorta
followed exactly the  curvatures of the
 vertebral  column,   and  throughout  its
 length, was  bound down  in such a man-
 ner, as to be doubled upon itself to the ex-
 tent of two inches.  The artery gradually
 diminished in size, towards the abdomen,
 to such an extent that the inferior portion
 of it was not more than a third of the dia-
 meter of the thoracic aorta.  The inferior
 extremities were in a state  of atrophy—
 probably in  consequence of the  obstruc-
 tion to the course of the blood through the
 narrowed portion of the vessel. (Surgical
 Pathology.  125. Plate V. fig. 5.)
  Narrowing of the  calibre of an artery
 may be the  result of a congenital defect
 of evolution: it may be produced by a sim-
 ple constriction  of the coats, more or less
 extensive,  taking place at any period of
 life, without any alteration of texture;  or
 it may arise  from cartilaginous, steatoma-
 tous, calcareous, or other deposits in the
 tunics of the affected vessel.  Several ex-
 amples of each of these varieties  of nar-
 rowing have been referred to in the arti-
 cle Aorta; and in some  instances the pul-
 monary artery experiences the same modi-
 fications of capacity.   Two cases of this
 kind  are described  by  Hellioston.   In
 one of them, the size of the vessel was so
 much  reduced  as scarcely to  admit the
 little finger,  and in the other,  it was not
 larger than the brachial artery. (Berard.
 Diet, de Med. IV. 116.)  A case was also
observed by Jacobson, in which the  indi-
vidual was affected with ^cyanosis.  The
pulmonary artery was not more than one-
fourth the size of the aorta, but the bron-
chial  arteries were  very much enlarged.
(Meckel's Archives fur Physiologie.  II.
 134. Berlin,  1816.)   Another example  of
the same disease has been described  by
Knox,  in  which the  pulmonary artery
 was reduced to  the  size of a small goose
quill.  (Edinb. Med.  and Surg. Journal.
XI. 57.)   Various other arteries of the
body are  frequently  found affected  with
more  or less narrowing or constriction.
 Sometimes, indeed, the capacity of nearly
the whole arterial system is found dimin-
 ished.   This is particularly observed  in
 individuals affected with general atrophy,
 phthisis pulmonalis,  and several other af-
 fections in which  the quantity of  blood is
 greatly diminished.   The atrophy of  an
 organ is likewise attended with a diminu-
 tion of the  capacity of its  vessels, and
 when  it is  extreme, the greater part  of
 them are sometimes entirely obliterated.
 Instances in which the  arteries are pre-
 ternaturally small in relation to the heart,
 are not unusual, many  such having been
 described by Morgagni  and others.  But 
418                ARTERIES. (Obstruction and  Obliteration.)
when  the  liability of the  latter organ to
become  enlarged is  considered,  the  im-
propriety of regarding all such cases as
examples of narrowing or constriction of
the vessels will be apparent.
   Obstruction and obliteration of the ar-
teries, like constriction, may be either con-
genital or acquired.   It  may take place
without  any  important alteration of the
texture of the vessel, or  at least without
any transformation or degeneration of its
tunics;—by  the  development  of coagu-
lated or  fibrinous concretions, or albumin-
ous deposits within  its calibre;—steato-
matous,  cartilaginous,  or  earthy  forma-
tions  encroaching upon, or filling up the
tube,  or by the  spontaneous  cure of old
aneurisms.
   The best examples of  the first are fur-
nished by  the obliteration of the  ductus
arteriosus,  and the umbilical arteries  of
the foetus, which takes  place as a natural
result after birth.  The obliteration of an
artery which follows  the  application of a
ligature, or the  long-continued influence
of pressure, seems also to partake some-
what of  this character; and in describing
the pathology of the aorta, we referred to
examples of constriction  and obliteration
of that vessel, which were of the same
nature.  In some instances the oblitera-
tion is of very limited extent, and presents
the appearance  of a thread  or ligature,
drawn tightly round the  vessel.   Some-
times it extends along the artery in a lon-
gitudinal direction to a considerable  ex-
tent and converts it  into a solid impervi-
ous chord.  When the constriction does
not entirely close the  artery, there is often
more or less dilatation of the vessel above
the narrowed  point,  and  in  some cases
also below.  This form of constriction and
obliteration, when it is congenital, is doubt-
less  owing to an arrest  of development
taking place in the part, and is analogous
to the  examples of atresia which are some-
times  observed  in other  hollow organs.
But when  it occurs at a  later  period of
life, it may be produced either by inflam-
mation and a deposit of coagulable lymph,
or by a species of organic contraction of
the coats of the vessel, which is more ac-
tive at the affected point than in any other
situation.   This  condition has been com-
pared to the spasm which  affects the hol-
low organs possessed of muscular  fibres;
but the parallel is not just because it is
the character of muscular spasms to  re-
lax, when  the exciting cause  ceases  to
operate.
  By far the most frequent cause of  ob-
struction and obliteration of arteries is, the
formation of fibrinous concretions within
their calibre, and the deposit of an albu-
minous or organizable fluid, which pos-
sesses the faculty of establishing adhesions
between the corresponding surfaces of the
lining  membrane.   There are  various
causes which are  capable  of giving rise
to  the formation  of these concretions.
They are  developed when  a  ligature  is
applied to an artery, or when the course
of the blood through it is interrupted for
some time  by pressure, or  in any  other
manner.   They also occur, sometimes,
when a partial laceration or violent con-
tusion has been inflicted, and always, if
we may confide  in the results of experi-
ments made on living animals, when an
incised wound implicates three-fourths or
two-thirds of the circumference. (Berard.)
In some cases, even slight wounds of the
smaller arteries are sufficient to produce
the effect; but in such instances, it seems
to be accomplished by the direct interven-
tion of the inflammation  excited by the
injury.  The agency of arteritis in the de-
velopment of fibrinous plugs or concre-
tions in the vessels, has already been  men-
tioned in a preceding section, and it is un-
questionably the most frequent cause of
the  species of obstruction  and  oblitera-
tion now under review.   The tendency
of inflammation of arteries of moderate
size to give  rise to coagulation of the
blood within them, is a fact now so well
established, that it cannot admit  of  a
doubt  But the manner  in which it pro-
duces this effect is  not  easy  to decide.
One of the effects of inflammation on the
arterial tunics  is, to produce  a tumid,
spongy, and rough disposition of the lining
membrane,  and  a  deposit of albuminous
matter, which forms a pulpy or flocculent
pseudo-membranous concretion upon its
inner surface.    These conditions will na-
turally tend to exercise a mechanical in-
fluence upon  the stream of blood, and it
is highly probable, that by interrupting or
retarding its transmission through the ves-
sel, they may  conduce to  the coagulation
of that fluid, and the development of the
fibrinous plugs  under consideration.   But
in addition  to this agency,  it may admit
of a question, whether an inflamed artery
is not capable  of exercising some vital in-
fluence directly upon the blood itself, dis-
posing it to coagulate, independently of
any  mechanical  impediment to its free
transmission through  the vessel.   This
opinion has been adopted by Cruveilhier,
Berard, and several other respectable pa-
thologists, and there are various circum-
stances which render it highly plausible. 
ARTERIES. (Obstruction and Obliteration.)
419
Amongst these, we may mention the very
early period at which these plugs are form-
ed after the inflammation has set in,  their
frequent coexistence with that condition in
arteries which are inflamed to a considera-
ble extent, and when no adequate changes
have taken place  in the lining membrane
to produce  the coagulation and conse-
quent obstruction by a mechanical  influ-
ence, and the intimate relationship which
exists  between  these  concretions  and
gangrene, in which traces of arteritis can
be almost always recognized, except when
the mortification results from some cause
purely mechanical in its operation.   We
have already adverted to the close con-
nexion  between arteritis and this latter
condition, and have remarked,  that in all
cases of spontaneous gangrene, the  arte-
ries are plugged up with fibrinous masses,
which are accurately moulded to their in-
ner surface,  and  very frequently occupy
their calibre even for a  considerable dis-
tance above the limit  of the mortification
—always almost  as high as the origin of
the  nearest collateral vessel  above that
point.   These plugs may be drawn out in
form of round, elongated masses, having
the exact impress of the  cavity of the ar-
tery.   They are generally soft and of a
fragile consistence; but it will sometimes
be found, if the vessel be cautiously laid
open, that  they adhere slightly at  some
points to the lining membrane, by means
of a viscid  albuminous material, which is
poured out by the inflamed tissue. Some-
times, indeed, distinct  pseudo-membranous
deposits are formed,  provided sufficient
time has elapsed,  and  the internal surface
of the artery is found  red, spongy, villous,
and exhibiting all the characters of  acute
inflammation.  Should all  the principal
arteries of a limb be obstructed in this
manner to a considerable extent, so  as to
cut off the necessary supply of blood, gan-
grene will speedily supervene; but  when
the obstacle is  of limited extent, and the
collateral  vessels  remain  pervious,  the
limb does not mortify, but plastic lymph
is poured out in considerable quantity be-
tween the inner surface of the artery and
the coagulum; the latter is gradually ab-
sorbed while the former becomes concrete
and organized; and the final result  is the
total obliteration of the vessel, and its con-
version  into a small  compact chord, of a
cellulo-fibrous consistence.
  In reference to the  connexion between
the formation of  these  fibrinous  obstruc-
tions in the arteries, and the development
of gangrene, it may  be proper to remark,
that some pathologists consider the coagu-
lation of the blood as a consequence mere-
ly of the  previous  death of  the parts,
and their inability to circulate the blood
through  themselves.  In whatever man-
ner this doctrine be construed,  it is liable
to many objections.  If the coagulation of
the blood,  and the  formation of these
fibrinous  plugs, were  consequences  of
gangrene, they should not be formed above
the  limit  of the  dead  parts—at  least
they  should not extend higher than the
origin of the  nearest  collateral  vessels.
Yet they are  not unfrequently observed
reaching far  above  that point  and  in
cases of gangrene  of the leg, have been
met with plugging up the main artery of
the limb, as high as Poupart's ligament,
or even farther.   Besides, the obstructed
artery in such cases, above the seat of the
gangrene, presents the  ordinary indica-
tions of inflammation.   If, as represented
by Alibert, the coagulation of the blood
were owing to a previous diseased condi-
tion of that fluid, and  the arteritis a con-
sequence of the formation of the fibrinous
concretions, there is no reason, as  Berard
has very properly remarked, why it* should
become consolidated in one set of vessels
in preference to another; nor  does it ac-
cord  with sound  philosophy to  attribute
spontaneous gangrene to this cause, when
the  whole category of the phenomena
which attend the form  of it  now  in ques-
tion,  indicates arteritis as the first link in
the  chain of causation—the coagulation
of the  blood, and  the  obstruction of the
vessels, as the second, and  the death of
the parts as the necessary consequence of
their supply of blood being cut off. These
principles were strikingly exemplified in
a case of spontaneous gangrene which we
had an opportunity of witnessing a few
months ago.   The  individual  was a lady
aged forty-five or fifty.   She was first at-
tacked with excruciating pain  of  the foot,
without  either redness, tumefaction,  or
elevation of temperature.  The parts soon
became cold and  cedematous,  and finally
gangrene made its appearance in the great
toe, and gradually extended up the leg, to
the vicinity of the knee,—the violent pain
 continuing all  the time without any abate-
ment.   The pulsation  of the popliteal ar-
 tery  was completely annihilated,  and that
 of the femoral was exceedingly  obscure,
 as high even as the vicinity of Poupart's
 ligament.   The   limb  was  amputated
 through the thigh, and on examining the
 arteries, they were all  found occupied by
 fibrinous  plugs, their   coats very  much
 thickened, and otherwise diseased.  The
 thickening existed also in  the popliteal 
420               ARTERLES. (Obstruction and Obliteration.)
and femoral arteries, to such a degree as
to diminish their calibre.  Here then we
have the development of arteritis attended
with acute  pain.   The  vessels  soon be-
came obliterated by the'Coagulation of the
blood within them and its conversion into
fibrinous plugs.   To this succeeded cold-
ness, extinction of pulsation, and oedema,
which,  it will be  remembered,  are  char-
acters  of arteritis attended with obstruc-
tion ; and as a final result gangrene was
developed. A few years ago, we witness-
ed almost precisely the same result in an
aged female, except that the oedema ex-
tended  as high as Poupart's  ligament,
and  the closure of the arteries reached
above  that point.  These facts strongly
corroborate the inference that arteritis  is
not only a frequent cause of obliteration
of the arteries, but that it tends  indirectly
to the  development of spontaneous gan-
grene.  It must not be inferred, however,
that it is always the cause of this disease;
since,  as we  have previously remarked,
it may be induced by various other condi-
tions.
  Inflammation affecting the larger arte-
ries, does not so readily give rise to ob-
literation, but often occasions considerable
obstruction  to the passage of  the  blood
through those vessels.   In such cases,
either albuminous pseudo-membranes form
upon the inner surface  of the  artery,  or
fibrinous concretions are developed in the
same situation, which adhere to  the lining
membrane for some distance, and  when
they attain a considerable degree of thick-
ness, encroach so much upon the lumen
of the vessel  as to leave a very narrow
passage for the transmission of the blood.
These  changes are frequently  developed
in some cases of dilatation of the arteries,
and they may likewise  take place  when
no previous augmentation of diameter has
occurred.
   Another frequent cause  of obstruction
and obliteration of the arteries  is, the de-
velopment of the various  alterations  of
their tunics, which have been described
in a preceding section, as consequences
of chronic inflammation.  The formation
of cracks and fissures in the lining mem-
brane, ulceration  and  erosion of that tis-
sue, the  development of calcareous and
steatomatous or atheromatous masses, and
various other morbid conditions  of the ar-
terial  tunics, all  have a tendency to im-
pede the even current of the circulating
blood, and a portion of that fluid  being en-
tangled by their  inequalities,  masses  of
 coaguli are  formed, which  by  continued
accretion, finally attain so large a size, as
to obstruct, or completely close the calibre
of the vessel.  It is not unusual for such
obstructions to take place in  old  persons,
in consequence of extreme ossification of
the arteries.  Several of the cases of ob-
struction and obliteration  of the aorta re-
ferred to under that head, were owing to
this cause; and its tendency to produce
gangrene,  when the arteries of the ex-
tremities are affected, was long since no^
ticed by Cowper.   (Phil. Transactions.
1703.)  We  have witnessed as many as
three cases of spontaneous gangrene of
the foot, which were owing to ossification
and obliteration of the  anterior tibial ar-
tery, and  the  connexion between these
two conditions has been so repeatedly no-
ticed by modern pathologists, that there is
at present  no question of the dependence
of many cases of spontaneous  gangrene
upon this cause.  A case, however, is re-
ported  by  Willis (Cerebri Anat.  Cap.
lxx.), in which the right carotid, and the
corresponding vertebral artery, were ossi-
fied and obliterated, yet the individual ex-
perienced no inconvenience. In the body of
a person who died of senile gangrene, Cru-
veilhier  found  the  orifice of the  right
carotid  obstructed  by a grayish-coloured
tumour of  a fibrinous consistence, and the
left internal  carotid ossified at its origin,
and entirely  obliterated as far as where it
enters the  petrous portion of the temporal
bone.  (Essai sur I'Anat. Path. II. 58.)
The same author  also mentions another
case, in which the left primitive carotid
was plugged by a red fibrinous concretion,
half an inch in  length, which was inti-
mately united to the  inner surface  of the
vessel, and the origin of the external ca-
rotid reduced almost, to a capillary tube
by a yellowish-coloured substance, covered
by several lamina? of a fibre-cartilaginous
texture.  The  external carotid, with its
branches,  was diminished very  much in
size. We have already referred to a case
observed by Stenzel, in which the aorta
was obstructed by two large steatomatous
tumours; and in addition to other exam-
ples  of obstruction and obliteration enu-
merated in the article appropriated to the
pathology  of that vessel,  the following
may be cited:  De Haen found nearly the
whole arterial system containing fibrinous
concretions.  (Rat. Med. II. Pars vi. Cap.
4.)   In a case observed by Petit, the ca-
rotid artery was obliterated and converted
into a  ligamentous chord.  (Mem.  de V-
Acad. des  Sc.  1765.)  Other examples of
obstruction and obliteration of this vessel
have been reported  by Haller (Opera
Minora.  III. 303.),  Darrach (Philada. 
ARTERIES.  (Perforation and Rupture.)
421
Journ. XIII.  1826.), and of the branches
of the internal carotid, by Hodgson. (Op.
Cit.  p. 32.)  Berard also states, that  in
an individual affected with gangrene of
one  hemisphere of the brain,  he found
the corresponding  arteries  obliterated by
fibrinous concretions. (Diet, de Med. IV.
119.)  Jauelot has described a case,  in
which both carotids were  obliterated by
ossification. (Naumann. Klinik.  II. 620.)
In the  case  observed  by Darrach, just
referred to, the innominata, and the adja-
cent portion of the right subclavian, were
also obliterated; and  Pelletan  has de-
scribed an instance,  in which the subcla-
vian and axillary arteries were fonnd in the
same condition. (Clinique Chirurgicale.
I. 77.)  Examples of obliteration  of the
brachial artery  have been described  by
Hodgson  (Op. Cit.), Ribes (Bulletin  de
la Faculte. 1817.),  Rostan (Journ.  de
Med.  I. 81.  1818.), and Pelletan (Op.
Cit. I. 68.). The external iliac was found
obliterated in a case of gangrene, by Bry-
ant. (Edinb. Med. and Surg. Journal.
XIX. 45.)  Ribes observed the same con-
dition in  the  popliteal artery (Op. Cit.),
Hodgson  in the femoral (Op. Cit. p. 22.;
and obliteration of the tibial arteries has
 been so frequently met with,  in cases  of
 gangrene of the foot and leg, that it is not
 necessary to  specify particular instances.
 When  glandular organs become greatly
 atrophied,  it is not unusual to find the
 principal part of their vessels either im-
 pervious, or so remarkably small, that they
 arc  incapable of conveying much  blood.
 This is often observed in  the liver, kid-
 neys, &c., and it constantly takes place in
 the  thymus gland some time after birth.
 The same change  sometimes occurs  in
 the  arteries of glands affected with cer-
 tain morbid developments. Not long since,
 we assisted our friend and colleague, Pro-
 fessor N. R. Smith, in the removal of a
 very large tumour of the  thyroid  gland,
 and notwithstanding the  extensive dis-
 sections which  were  necessary, he was
 scarcely obliged to  tie any  other  artery
 than the superior thyroid of the right side
 —all the rest being either obliterated, or
 bo small as not to require a ligature.
   The manner in which aneurism is some-
 times cured  spontaneously, by the oblite-
 ration of the sac and the adjacent portion
 of the  vessel, has been described  in  the
 article which treats of that disease. An-
 other cause of obstruction of arteries has
 been mentioned by Turner, which in  its
 nature presents many points of analogy
 with aneurism.  It consists in the lacera-
tion of the lining membrane of the vessel,
   vol. ii.          36
and its detachment to such an extent that
by projecting into the cavity,  it forms an
obstacle  against  the  free  passage  of the
blood, which consequently becomes coagu-
lated, and  finally occasions complete ob-
literation,  attended with coldness  of the
limb, want of sensibility,  oedema,  gan-
grene, and the ordinary phenomena at-
tendant on obstruction from other causes.
This condition  is analogous  to the dis-
secting aneurisms described by Laennec,
Guthrie,  and  others, and  is most apt to
occur in the vicinity of the movable arti-
culations.  It cannot  take place,  unless
the  coats of the vessel be previously dis-
eased ; because under other circumstances,
their elasticity and  powers of resistance
will be adequate to protect them against
injury.   Several cases of this form of ob-
struction have been  reported by Turner
(Transactions of the Medico-Chirurgical
Society of Edinburgh. I. 105 and 308.);
and the same condition of the arteries has
been described  by  Laennec,  Hodgson,
Guthrie,  Lobstein,  and others.
   The consequences  of obstruction and
obliteration of the arteries are exceedingly
variable, according to the extent of the
closure, and the  freedom of the collateral
anastomoses. They have been so far point-
ed out in the course  of the preceding re-
marks, that  they need not be detailed in
the present place.  It will be sufficient to
remark, that when  the obstruction occu-
pies a  great extent of a principal artery,
gangrene  will very generally ensue.  This
does not often happen when the closure is
of limited extent; because under such cir-
 cumstances, the anastomosing vessels be-
 come sufficiently enlarged to compensate
 for  the  suspension  of the circulation
through the main trunk.  This takes place
 as well when a ligature  is applied to an
 artery, as when it is obliterated sponta-
 neously.   Whether it is accomplished en-
 tirely by  the simple  enlargement of the
 anastomosing arteries already existing, or
 partly by the development of new vessels,
 is a question not yet satisfactorily decided.
 We shall not,  however, discuss the sub-
ject in this place, but refer for further in-
 formation, to the articles Aneurism, Liga-
 ture, and  Capillaries.
   Obstruction of the arteries may also
 produce  paralysis of the affected limb
 (Rostan,  Bogros,  Berard,  Op.  Cit.  p.
 120.), atrophy of the  parts to which it  is
 distributed, and preternatural dilatation of
 other portions of the  arterial system with
 all  its consequences.
   § 4. Perforation and rupture of the arte-
 ries. The coats of the arteries may be per- 
422
ARTERIES.  (Wounds.)
forated or ruptured, either in consequence
of changes commencing primarily in them-
selves, or by the influence  of causes  ope-
rating on them from without, or extending
to them from the adjacent structures.  To
the first class  of causes we may refer the
various alterations  of  texture described
under the head  of inflammation;  as  soft-
ening, attenuation, ulceration; atheroma-
tous,  steatomatous, calcareous, and other
deposits;—also aneurism:—to the second,
ulceration, mortification, cancerous dege-
neration, and other analogous morbid con-
ditions originating in the structures adja-
cent  to the vessel;—wounds and contu-
sions ; spiculae of bone; violence inflicted
in dislocations or in attempts to reduce
them  after they have existed long enough
to allow the vessel  to  contract preterna-
tural  adhesions,—and the  contusion and
laceration inflicted upon the neighbouring
parts  by  the passage of a ball, or other in-
juries of a similar nature.   Most of these
causes, it will be observed, operate either
by occasioning a direct solution of conti-
nuity, or by so far enfeebling the  texture
of the walls of the vessel, that  they be-
come incapable of sustaining the disten-
sion or impulse occasioned by the  circula-
tion of the blood.  Under the latter cir-
cumstance, the mischief proceeds gradu-
ally:  by  disease, the  thickness  or the
cohesive  power  of the vessel  becomes
so  far diminished,  that under   the  in-
fluence  of some  bodily  exertion,   the
weakened  point  gives way,  and   the
blood is   either extravasated in  the sur-
rounding  tissues,  thrown  into   one of
the natural cavities or hollow organs, or
discharged externally.  In the first case,
the rupture or perforation gives rise to a
diffused  aneurism:  under  either of the
other circumstances, the individual is de-
stroyed by hemorrhage, unless the artery
should be small, or so situated as to admit
of surgical relief.   It rarely happens that
an  artery is ruptured without any previ-
ous disease of  its  tunics.   Yet  such an
accident  sometimes  takes   place  from
great violence, or a sudden commotion,—
as in falling from a height—by the body
being crushed between two  solid points
of resistance,  or by a heavy weight pass-
ing over it and when  an artery is  forci-
bly elongated  or twisted.
  Rupture  of the  aorta has been consi-
dered in  a previous article, and numerous
examples were referred to.   We might
cite a great number of  cases of the same
accident happening in other vessels, were
it not that they are too  numerous to be no-
ticed  individually. Those who may desire
to refer to such cases, will  find a copious
list of citations in Ploucquet (Bibliotheca
Med. Practica. I. 423.), and Otto (Lehr-
buch der Pathologisch. Anatomic I.  333
and 338.
  $.  5.  Wounds and injuries of arteries.
Few subjects pertaining to  surgical pa-
thology are more important  than wounds
and  other  injuries of the  arteries.  The
alarming   and   often  fatal  hemorrhage
with which they are  attended, independ-
ently of their  liability to occasion  gan-
grene  of the parts receiving their blood
through the injured vessel, renders them
an object deserving the closest attention,
since it is only by a proper understanding
of the important steps adopted by nature
to obviate  or overcome their formidable
consequences,  that the  surgeon can be
qualified to institute  a rational and suc-
cessful method of treatment.  Under the
head of injuries of the arteries, may be
included, 1. punctured, 2.  incised, and 3.
lacerated wounds, implicating either  one
or more of their tunics; contusions result-
ing  from external violence, and the pre-
ternatural stretching of their tissues which
takes place from violence operating upon
parts  through   which  they  pass.  The
changes produced in them  by the applica-
tion  of ligatures for the  suppression of
hemorrhage, fall properly under the same
head;  but  as they will be considered in
an article  appropriated  specially  to that
subject, they will only  be noticed  inci-
dentally in the  present article.
  1. Punctured wounds of the arteries.
Experiments on animals have shown, that
when  an  artery is punctured by a fine
sharp-pointed  round  instrument,  as, for
example, a needle, the blood  which issues
from the orifice is extravasated beneath
the adjacent portion of the sheath, and in
the meshes of the cellular tissue surround-
ing  the wounded portion  of the  vessel.
This coagulates and forms  a small pro-
jection, or thrombus, which effectually
closes up the puncture.  After the expira-
tion  of a few hours, coagulable  lymph is
effused by  the  irritated  vasa  vasorum,
which agglutinates the meshes of the tis-
sue ; and in the course of a  few days the
coagulated blood is absorbed, and the plas-
tic  lymph  effused in the  vicinity of the
injury becomes  consolidated  and forms a
small cicatrix,  which effectually restores
the  breach made in  the  arterial tunics,
and leaves  them in possession of as much
strength as they had before the  infliction
of the wound.   The  course  of the blood
through the artery is  not in  the slightest
degree interrupted, and if the vessel be 
ARTERIES. (Wounds.)
423
laid open after the cure is effected, it will
often be impossible  to discover upon its
inner surface the exact seat of the punc-
ture. In some instances, however, a small
point of variable extent, differing from the
adjacent portion of the lining membrane
in colour, will indicate the site of the ci-
catrix,, and if considerable inflammation
has existed, this will be the more conspi-
cuous.   It may happen, indeed, when the
wounded artery is not very large, and vio-
lent inflammation ensues, that a consider-
able effusion  of coagulated lymph takes
place within the vessel,  attended  with
the formation of a  fibrinous concretion,
and a complete obliteration of its calibre,
as  sometimes  occurs  from  arteritis  in-
duced by other causes.   The salutary ef-
forts of nature may, besides, be thwarted
by the development of ulceration.  Guth-
rie states that in two instances in which
he saw the femoral artery wounded by the
tenaculum, ulceration followed by hemor-
rhage took place, requiring the applica-
tion of a ligature.  (Diseases and injuries
of the arteries, p. 212.)
   2. Incised wounds of arteries may be
divided according to their depth, into those
which merely sever the external tunics,
and such  as penetrate the cavity of the
vessel.
   a.   Superficial,  or  non-penetrating
wounds. The simple division of the sheath
of an artery does not usually occasion any
serious consequences.   A slight oozing of
blood takes place for a short time, but co-
agulable lymph is  soon poured  out, and
the injury is repaired in the same manner
as in simple wounds of other parts;  or if
the external opening of the integuments
be not closed, suppurtttion may ensue, and
the part will be  healed by granulation.
Should  the cellular coat of the vessel be
divided  simultaneously with the sheath,
the fibrous and internal coats will usually
possess  sufficient  strength to prevent the
development of any dilatation at the seat
of injury, and the  solution of continuity
will be repaired in the same manner as in
wounds confined to the sheath.  Such an
injury will seldom give rise to aneurism
—probably never, unless considerable in-
flammation should take place, occasioning
softening of the fibrous coat; in which case
it is possible that it  might yield to the dis-
tending influence of the blood, and form
an aneurismal tumour, as represented by
Callisen. This accident will be still more
apt to occur if the wound should suppu-
rate;  and under such circumstances, per-
foration may finally take place, without
any previous dilatation of the  vessel  at
the seat of injury,  giving  rise  to fatal
hemorrhage.   A wound  penetrating  still
deeper, so as to divide the fibrous  coat
partially or completely, constitutes a much
more  serious injury.  In such cases, the
walls of the vessel are rendered too feeble
to sustain the impetus of the column of
blood,  and the thin lining membrane  will
either become dilated at the seat  of the
wound, so as to protrude through the open-
ing of the other tunics in form of a small
thin aneurismal sac,  or  it will give  way
and  occasion profuse hemorrhage.   In
speaking of mixed aneurism  of the aorta,
it was remarked that Haller had long
ago proved by experiments made on the
mesenteric arteries of frogs, that aneu-
rismal dilatation of the  lining membrane
took place when the  cellular and fibrous
coats of the  vessel were destroyed;  and
notwithstanding  the assertion  of John
Hunter,  that  the deposit of coagulable
lymph at the seat of such injuries renders
the coats of the vessels thicker and strong-
er than at other points, subsequent observa-
tions of Dubois, Dupuytren, Trousseau
and Leblanc, and Lauth,  prove clearly
that such aneurisms may form from the
destruction of the  outer tunics of an ar-
tery.   In some cases, however, no dilata-
tion takes place, but the internal tunic re-
sists the distending influence of the blood,
until  it  becomes weakened by disease,
when it  ruptures  and  a copious hemor-
rhage results.   A case  is mentioned by
Guthrie, in which a penetrating wound
of the neck partly severed the internal
jugular vein, and at the same time divided
the cellular and fibrous coats of the caro-
tid artery.  The lips of the wounded vein
were pinched up and surrounded by a liga-
ture, leaving the calibre  of that vessel per-
vious.  The artery was not tied,  and on
the eighth day,  the internal coat  gave
way, and hemorrhage took place.  A liga-
ture  was then applied to both the lower
and upper ends of the artery, there being
profuse reflux bleeding; but the individual
died the next day. (Op. Cit.  p. 328.)
   b.  Penetrating wounds.  When an ar-
 tery  has been wounded,  the  consequences
 will  be different according to the size  of
 the vessel injured.  The extent and di-
 rection of the  wound  will  also exercise
 more or less  influence upon the pheno-
 mena developed,—the changes induced by
 a partial division  of the vessel in either a
 longitudinal, transverse, or oblique direc-
 tion, being somewhat different from  those
  which follow when it is cut entirely across.
  If the injury be confined to the small ar-
  terial ramifications,  there   is merely  a 
424
ARTERIES.  (Wounds.)
trickling of blood from the wound, which
gradually  diminishes   in  quantity,  and
finally disappears.  The space  between
the  lips of the  severed tissues will be
found, when the bleeding has ceased, filled
by a mass of coagulated blood, and after a
short time coagulable lymph will be poured
out, the coagulum will be  gradually ab-
sorbed, and the solution of continuity will
be restored by adhesive inflammation. But
when an artery  of considerable size is
wounded,  either  by a  puncture with a
sharp instrument or by a clean incision,
the  bright vermilion  arterial  blood  is
thrown out in jets, corresponding  to the
systole  of the heart, and describing un-
equal parabolas.   The stream will cease
when the  artery  is compressed  between
the wound and the heart, but will be gene-
rally increased when the pressure is  ap-
plied to the vessel beyond the seat  of the
injury.   The  manner  in which the blood
escapes  may, however, be  considerably
modified by contingent circumstances. It
may happen, from the great  depth  of the
vessel, the character and extent of the in-
jury, and the relations of the external parts
with  the opening in the vessel,  that the
jet of blood will be broken,  so  as  not to
issue per saltern,  but flow from the wound
in a uniform stream.   This  will be more
apt to occur when the  external wound is
narrow,  and especially when,  from the
mobility of the parts, or the  retraction of
the artery, the relations of the wound of
the vessel with that of the sheath become
changed.   A careless  examination under
such  circumstances might lead to the in-
ference that no artery has been wounded,
because the blood  is not thrown out in
jets; but if in addition to the vermilion
hue  of the blood, it is remarked that  it is
discharged in waves, which are synchron-
ous with the systole of the heart, such a
mistake can be readily avoided.
  Should the external opening be too nar-
row to allow the blood  to escape freely, or
the relation between the opening of the
artery and  its sheath,  or the surrounding
structures, become altered, that fluid will
be driven extensively into the cellular tis-
sue, where it will form a diffused mass of
coagula beneath  the fascia, to which a
general thrill will be communicated by
the projection of the  fluid  blood  into it
through the orifice of the vessel, at each
contraction of the ventricle.  The part
thus affected, generally presents,  when
the extravasation  is considerable, a dark
or blood-shot appearance, and often has
one point softer than the rest,  in which
the blood preserves its fluid character, and
the  pulsation communicated to it by the
wounded vessel can be distinctly felt.  This
constitutes the condition denominated pri-
mitive diffused aneurism, which has been
described in a previous article. (See An-
eurism.)
   When the wound  is first inflicted, the
blood issues from  the vessel with great
impetuosity; but after it has flowed for a
few seconds, the action of the heart be-
comes so feeble, that the stream is pro-
jected with less  force, the  blood is  infil-
trated in the meshes of the adjacent tis-
sues, and beneath  the sheath of the ves-
sel,  where it coagulates and forms an ob-
stacle to the continuance of the  hemor-
rhage, and  if artificial means  be  not re-
sorted to for the purpose of arresting it,
syncope  finally takes place  from the ex-
cessive loss of the vital fluid. In this con-
dition all bleeding ceases, and during the
quiescent state of  the heart and arteries,
still more extensive coagula form around
the vessel at the  seat  of injury and in its
orifice, so that in  many cases, after the in-
dividual revives, the circulation being lan-
guid, the barrier thus formed prevents the
recurrence of hemorrhage, and a cure may
be effected by the spontaneous efforts of
nature.   Very often, however, these salu-
tary provisions only afford  a  temporary
respite;  for so soon  as  animation is re-
stored, and  the circulation  regains some
power, the coagula plugging up the orifice
of the wound give  way, thus giving rise
to a renewal of the bleeding, which may
be again  suspended by the same causes,
or it may continue until life is destroyed
by the loss of blood.   This  is what takes
place when  the case is left to the unas-
sisted powers of  nature, and in many in-
stances, the alternate  suspension and re-
newal of the hemorrhage occur several
times before it is  finally arrested, or death
ensues.   The facility with which the flow
of blood is stopped by the concurrence of
the circumstances just adverted to, will be
so much influenced by the  character and
extent of the wound, that it will be neces-
sary, in  order to  comprehend the manner
in which it  is  accomplished, to consider
the changes which  ensue when the artery
is completely  divided,  and to compare
them with  those which are  developed
when it is only severed partially, by either
a  longitudinal,   transverse,  or  oblique
wound.
  a.  Spontaneous  cessation  of hemor-
rhage when an artery is entirely divided.
If an artery of large size be entirely cut
across, the  blood will be projected  from
the wound with  considerable force, and 
ARTERIES. (Wounds.)                         425
will generally continue to flow until death
takes place, unless some  artificial means
be resorted to for the purpose of arresting
it  Sometimes, nevertheless,  if the ex-
ternal opening be very contracted, and es-
pecially if the lips of the wound be  nar-
row, the enfeebled action  of the heart and
arteries induced by the loss of blood, the
total suspension of the circulation by syn-
cope, together with  the retraction of the
divided artery within its  sheath,  may
allow  the orifice of  the bleeding  ves-
sel and the adjacent parts  to  become so
plugged up  with coagula, as  to prevent
a recurrence  of  the  hemorrhage when
the patient revives, and thus secure a fa-
vourable termination.  This fortunate is-
sue will be still more likely to be realized,
when  the wounded  artery is small or of
medium  size; for  under  such circum-
stances, the  conservative powers of na-
ture will  often be  found  sufficient  to
prevent the hemorrhage  from continuing
sufficiently long  to  destroy  life.   This
being  the case,  it  becomes essential
that the surgeon  should be  acquainted
with the steps by which so important an
object  is consummated as the spontaneous
cessation of hemorrhage, since upon this
 knowledge should be predicated the  arti-
 ficial means he adopts to secure the  same
 end.
   The ancients, though  acquainted with
 most of the means at present employed to
 stop the flow  of blood  from  wounded arte-
 ries, did not  understand the  manner in
 which they accomplish that end.  To Pe-
 tit we are indebted for the first  rational
 explanation of the process by which he-
 morrhage is arrested spontaneously.  From
 numerous observations, he arrived at the
 conclusion, that the bleeding from a di-
 vided artery is arrested by the formation
 of a clot partly within the vessel, and in
 part exterior  to its cavity.  The external
 coagulum he  supposed is formed by the
 last drops of blood as they are issuing
 from the wound; the internal, which  he
 says is small, is formed by the portion of
 the blood still contained within  the end
 of the  artery.  The outer  coagulum, which
 surrounds the end of the wounded vessel,
 he denominated couvercle, or cover, while
 to the inner one he  applied the appella-
 tion of bouchon,  or  cork.   Having ex-
 plained the manner in which the wound
 is closed  by  these  two  coagula, he sub-
 joins,  that a whitish substance is mixed
with the rest of the  mass, which unites
the clot to the surface of tlie vessel.  (Me-
moires de l'Acad. des Sc. 1731.)
   This explanation, as far as it goes, is
                  36*
highly satisfactory; but as it does not in-
clude the changes which take place in the
end of the vessel itself, the infiltration of
the blood into the  surrounding cellular
tissue, and some other collateral circum-
stances,  it is defective.   Morand,  per-
ceiving these objections, made an impor-
tant addition to the doctrine of his prede-
cessor, by explaining the manner in which
the vessel itself, as well as the blood, per-
forms  an important, part  in suppressing
hemorrhage.   Admitting the agency of
the coagula as it had been  explained by
Petit, he attributed still more importance
to a kind of corrugation of the coats of the
artery, resulting from  the contraction of
its circular fibres,  and a shortening of the
vessel, produced,  as he supposed, by the
contraction  of longitudinal  fibres.   The
longitudinal fibres, it is now well known,
do not exist in the arteries;  yet the con-
traction  of the end of the wounded ves-
sel,  and its retraction  within  its sheath,
cannot be denied, and Morand only erred
in his manner of explaining one of these
changes.   They both constitute very effi-
cient  steps in the process by which he-
morrhage  is suppressed, and form an im-
portant addition to the  explanation  previ-
ously offered by Petit.
   The doctrine of the  spontaneous  cessa-
tion of bleeding  from  wounded arteries,
thus  improved, was adopted  by  Sharp,
who,  in making the assertion, that the
blood-vessels, immediately upon their di-
vision, bleed freely, and continue bleeding
till they are either stopped by art, or at
length contracting and withdrawing them-
selves into the wound, their extremities
are shut up by the coagulated blood, very
properly blends the explanations of both
Petit and Morand.
   Pouteau strongly contested the accu-
racy of these opinions.  He affirmed that
 in many cases no coagulum  is formed
 within the vessel, as  represented by Pe-
tit, and that in several amputated stumps
 which he examined several days after the
 operation, when the hemorrhage had been
 commanded  by ligature,  compression, or
 caustic, he seldom found any traces of co-
 agulum.   Even  when it  does occur,  he
 denies that  it performs any efficient part
 in stopping the blood, since it is too small
 to close the vessel, which is, notwithstand-
 ing, obliterated.   He also denied  that the
 vessel retracts,  and in  corroboration of
 this assertion, stated that he had seen ar-
 teries hanging out from  the  stump after
 amputation of the penis, and the fore-arm.
 Instead,  therefore, of adopting the doc-
 trine of Petit and Morand, he attributed 
426
ARTERIES.
(Wounds.)
the cessation of hemorrhage to the tume-
faction of the parts surrounding the  ar-
tery,  and the consequent pressure upon
the vessel.  Hence, with the view of pro-
moting the swelling and induration of the
surrounding  structures,  he  proposed,  in
applying the ligature, to include them in
the knot.  It should be remarked, how-
ever, that in arriving at these conclusions,
Pouteau was influenced by the condition
presented by the wounded  arteries some
time after the bleeding had been arrested
by artificial means,  and  that he rejected
an experiment made on a horse, in which
the artery was found in the  condition re-
presented by Petit, as not  applicable to
the point.
   According to Gooch, hemorrhage from
divided arteries is arrested by the retrac-
tion of the vessel, which collapses and co-
alesces as far as its first ramifications, and
has  its mouth soon sealed up with flesh,
growing from the nutritious vessels;  and
a similar opinion is adopted by Kirkland,
White, and Aiken.  The  first of these
gentlemen adduces some  experiments to
prove, that the spontaneous cessation of
hemorrhage is  owing to the contraction
of the  end of the artery; but it has been
very properly remarked by Jones, that his
inferences are  invalidated, because,  in-
stead  of leaving the wound to the opera-
tions of nature, he employed pressure, and
 even  resorted to the application  of the
 ligature and other means, which would of
 course materially modify the changes su-
 pervening after the infliction of the wound.
 The results of his  investigations led  him
 to the conclusion, that the bleeding is not
 suppressed  by  a coagulum, but  by the
 close contraction of the vessel to the ex-
 tent of an inch or more from its extrem-
 ity.   He nevertheless admits, that if the
 hemorrhage be  suppressed by placing a
 piece of agaric near the orifice  of the ves-
 sel, instead  of placing it over it, a coagu-
 lum may form  in  the  orifice; yet  both
 himself and White, who adopted all his
 views, affirm that  this is more  prejudicial
 than otherwise, and the latter represents,
 that except  when it is so situated as to be
 excluded from the air, it  ought to be re-
 moved.
   John Bell adopted a still more limited
 view of the subject, and  after reviewing
 the doctrines of his predecessors, he ex-
 presses his own opinion to the effect  that
 when hemorrhage  stops of its own accord,
 it is neither from the retraction of the ar-
 tery, nor the constriction of its fibres, nor
 the formation of clots, but by the cellular
 tissue which surrounds the artery being
injected with  blood.  This  blood  coagu-
lates and  forms a sufficient barrier to re-
strain the bleeding of a small artery, till
the parts  inflame,  and the  artery  is en-
tirely stopped.
  The doctrines relating to the spontane-
ous cessation  of hemorrhage remained in
this state of contradiction and uncertainty,
until Jones, actuated by a desire of arriv-
ing at the truth, instituted a laborious se-
ries of experiments, which  resulted in a
complete confirmation of some of the views
of Petit, with the establishment of some
new principles besides, which perform an
important part  in  the process.  Similar
experiments were subsequently performed
by Beclard, and since his time they have
been repeated by several individuals, with
a general confirmation of the views adopt-
ed by both Jones and himself.  These ex-
periments prove " that the  blood, the ac-
tion and even the  structure of the arte-
ries, their sheath,  and  the cellular sub-
stance connecting them with it,—in short,
that all the parts concerned in or affected
by hemorrhage, contribute to arrest its fa-
tal progress, by operating, in the case ofa
divided artery of moderate size, in the fol-
lowing manner:
   "An impetuous flow of blood, a sudden
and forcible retraction of the artery within
its sheath, and a slight  contraction of its
extremity, are the immediate and almost
simultaneous  effects of its division.  The
natural impulse, however, with which the
blood is driven on,  in some  measure coun-
teracts the retraction, and' resists the con-
traction of the artery.  The blood  is ef-
fused into the cellular substance between
the  artery  and  its sheath, and  passing
through the canal of the sheath which had
been formed  by the retraction of the  ar-
tery, flows freely externally, or  is extra-
vasated into the surrounding cellular mem-
brane,  in proportion to the open or con-
fined state  of the  external wound.  The
retracting artery leaves the internal sur-
 face  of the sheath uneven, by lacerating
or stretching  the cellular fibres that con-
nected them.   These fibres entangle  the
blood  as  it flows, and thus the foundation
 is laid for the formation of  a coagulum at
 the mouth  of the  vessel,  and which ap-
 pears to be completed by the blood, as it
 passes  through this  canal  of the  sheath,
 gradually adhering and coagulating around
 its internal surface, till it completely fills
 it up from the circumference to the cen-
 tre.  A certain degree of obstruction to
 the hemorrhage, which results  from the
 effusion of blood into the surrounding cel-
 lular membrane, and  between the artery 
AltiJ^iliHiO. {Wounds.)
427
and its sheath, but particularly the dimin-
ished force and velocity of the circulation,
occasioned by the hemorrhage,  and the
speedy coagulation of the blood,  which is
a well-known consequence of such dimin-
ished  action of the vascular system, most
essentially contribute to the accomplish-
ment  of this important  and desirable ef-
fect" (Jones.  On the process employed by
nature in suppressing hemorrhage, p. 53.)
   It will thus be seen, that one of the first
steps, after the retraction and contraction
of the artery, is the formation of a coagu-
lum within its sheath, and in the surround-
ing cellular tissue.  This is the couvercle
of Petit, and the external coagulum of
Jones.  It appears  on first examination,
like a continuation of the artery; but on
cutting open the latter, its mouth is found
completely closed by the coagulum, which
is also inclosed in the sheath.  The blood
being thus prevented  from  escaping, that
portion of it which remains within the di-
vided end of the artery, coagulates and
forms a long slender conical clot, the point
of which looks towards the heart.  This
generally extends as high as the  origin of
the nearest  collateral branch, but neither
fills the vessel, nor adheres to its tunics,
except at its base, where it also becomes
continuous with the  external coagulum.
This was denominated bouchon by Petit,
and constitutes the  internal coagulum of
Jones.  The connexion  between  it and
the external coagulum, and the relation
of both of them with the orifice of the di-
vided artery,  have  been aptly compared
by Beclard,  to  the  mouth of a bottle
closed by its cork,  and sealed over with
wax.
   It will be seen from  this description,
that the internal coagulum is too small to
fill the calibre of the  artery, except at its
base,  where, as we have just remarked, it
adheres to the inner surface of the vessel,
and also becomes continuous with the ex-
ternal coagulum.  It is  only at the latter
point therefore, that it can  exercise much
influence in  restraining  the hemorrhage,
and it is consequently much less efficient
in accomplishing that object, than the co-
agulum which forms in the sheath of the
artery and the surrounding  cellular tissue.
In some cases, indeed, no internal plug is
developed.   Its absence  in several cases,
we have  previously  remarked, was ad-
duced  by Pouteau,  Gooch, Kirkland-,
and White,  as an argument against the
doctrine of  Petit; and it  will often  be
found wanting when a large  collateral
branch takes its  origin near the point at
which the trunk of an artery is divided—
also when the vessel has been obliterated
by ligature, as after amputation, &c. Guth-
rie indeed  seems to think,  that there is
considerable difference between the means
by which hemorrhage is arrested in small
and in large arteries—that too much in-
fluence has been generally attributed  to
the heart, and that those who have adopted
tlie opinions of Jones,  have  ascribed too
much to the retraction of the artery with-
in its sheath, and have not duly considered
the importance of the contraction of the
vessel itself.  He mentions several cases
in which the artery could not retract with-
in the sheath,  because it hung pendulous
from the wound—yet the bleeding ceased
spontaneously in a few minutes.   He  re-
presents that when an  artery of the  size
of the femoral is divided, it retracts with-
in its sheath, but this retraction is also ac-
companied by a contraction of the orifice
or extremity,  which gradually  assumes
the shape of a Florence  oil flask, or French
claret bottle.  The contraction of the di-
vided end of the  artery is  confined in the
first instance to its very extremity, so that
the barrier opposing the flow of blood is
formed by  this part alone.   In proof  of
this,  he states that in one case he cut off
the  end of the artery at less than the
eighth of an  inch  from  the  extremity,
when it bled with its usual vigour.   The
contraction of the vessel goes on increas-
ing for the  space of an inch, and the in-
side of the contracted  portion is filled  up
with  an internal coagulum, which taken
the shape of, and adheres to, the inside of
the artery, rarely  extending as far as a
collateral branch, or under almost any cir-
cumstances, beyond  a couple of inches.
(Diseases and injuries of the arteries,  p.
246, 247.)  Berard, moreover, expresses
the opinion, that when the internal coagu-
lum is found much smaller than the  cali-
bre of the vessel, it is because the latter
was firmly contracted upon it during life,
but expands after death.  (Diet, de Med.
IV. 78.)  However this may be, we think
the internal coagulum, when it exists,  al-
though small, exercises more influence
than  many have been  disposed to allow.
If it  does  not entirely fill the calibre  of
the  artery, it will  serve to break  the
force  of the impulse of the blood, and as
it besides adheres to the inside of the ves-
sel at the  point  at which the latter is  di-
vided, and  is also continuous with the ex-
ternal coagulum, it will form a considera-
ble obstacle to the continuance of the he-
morrhage,  particularly as  its influence
 will  be aided by the  contraction of the
artery. 
424                         ARTERIES.

  These different acts taken collectively,
constitute the first step adopted  by nature
to arrest hemorrhage  from divided arte-
ries.  The  infliction of the injury on the
vessel is, however, soon followed by in-
flammation ; the vasa vasorum pour out
plastic lymph, which accumulates between
the internal coagulum and the  surface of
the  artery, between  the latter  and its
sheath, and even  in  the meshes of the
neighbouring cellular tissue.  This mate-
rial gradually becomes concrete, aggluti-
nates all the parts in which it is  deposited,
and converts  them into a dense, whitish,
or, greenish-coloured friable mass, in which
it is difficult to recognize the different
component  parts.  The adventitious de-
posit adheres intimately to the  inner sur-
face of the vessel, unites it slightly to the
coagula, and at the same time establishes
a close bond of union between the artery
and all the parts situated in the immediate
vicinity of the wound.  In proportion as
the coagulable lymph is effused, the inter-
nal coagulum is  absorbed, and  the vessel
continuing to contract it is found at the
expiration of a few days, that by the con-
solidation of the  plastic lymph, and its in-
timate adherence with the arterial tunics,
the whole arrangement  is converted into
a dense, compact impervious chord, as far
as  the  nearest  collateral branch, which
precludes the possibility of the  future es-
cape of blood, and diverts the  whole of
that fluid into the collateral vessels.  Fi-
nally,  by subsequent changes,  the whole
of the adventitious deposits are  removed ;
the  neighbouring cellular tissue has its
permeability restored ; the remains of the
obliterated  artery  are converted into a
dense filamentous band in which no traces
of the arterial tunics  can be recognized,
and the anastomosing vessels  are found
enlarged  and tortuous,  and carrying on
the  circulation as perfectly as it was pre-
viously done by the main trunk  of the ar-
tery itself.
  Jones  inferred from  his experiments,
that the same changes take place in the
inferior portion of the vessel, or that which
is most remote from the heart as occur in
the  superior, with  this  difference  only,
that its orifice is generally more contract-
ed, and  the external coagulum is much
smaller than the one which adheres to the
mouth of the superior portion  of the ar-
tery, or that from which the blood flows in
its direct course  from the heart. (Op. Cit.
p. 56.)  Guthrie,  however, has  adopted
views somewhat different.   He asserts
that the retraction and contraction of the
lower end are neither so perfect nor so
 (Wounds.)

permanent, as at the upper end,  and that
the internal coagulum is in many  instances
altogether wanting or very defective in its
formation;  giving rise to a very different
result  from that  which  is observable in
the upper divided end of the same vessel.
(Diseases and injuries of the arteries,  p.
251.)  He represents, moreover, that the
lower end of a divided artery is more prone
to secondary hemorrhage than the upper;
so much so,  indeed,  that when  it occurs
after having been arrested for a  period of
four hours, the bleeding takes place in all
probability from the lower end.  This may
always be known from the darker colour of
the blood, and from its flowing out in a con-
tinuous stream, and not with any arterial
impulse. (Op. Cit. p. 248.)  Notwithstand-
ing he declares that this assertion  is fully
justified by extensive observation, we think
it ought not to be adopted without consi-
derable qualification.  When the wounded
artery has  a very free anastomosis, as the
temporal and occipital,  the carotids,  tlie
brachial at the bend of the  arm,  the radial
or the ulnar in or near the palm of the
hand, the tibial, plantar, &c., it very often
happens that two streams of blood escape
from the wound even at the time the in-
jury is inflicted, and when this does not
take place, there is  generally so great a
proneness  to hemorrhage from  the lower
end of the vessel 6ome time after the up-
per has been secured, as often to render it
necessary to apply a ligature to both, or to
command the lower one by pressure. This
accident results from the lower part of the
artery becoming filled with blood through
the anastomosing branches, and this fluid
then  regurgitating  through the  wound.
In such cases as these, the observation of
Guthrie is  not  without foundation;  but
applied to  the generality of instances, it
is altogether too sweeping in its  charac-
ter,  and so far as our own experience has
extended, is not justified by facts.
   Some pathologists, observing the re-
markable tendency of the blood to be  di-
verted into collateral branches, instead of
continuing its course along the upper end
of one which has been cut across or ob-
structed, and  considering  that  the capil-
lary vessels possess the faculty of attract-
ing the blood through the medium of the
larger arterial branches which convey that
fluid, have imagined that  this attractive,
or as  it has  been denominated  by some,
suction power of. the extreme vessels, ex-
ercises  an important  influence  on the
changes by  which  hemorrhage  from a
bleeding artery is arrested.   The disposi-
tion of the blood to be diverted  from the 
                            ARTERIES.

wounded portion of the artery into  the
collateral branches, was long since noticed
by Haller.  He observed that when he
applied a ligature to one of the mesenteric
arteries of a frog, the blood contained in
the vessel immediately became quiescent
and  that numerous globules accumulated
along  the middle of the vessel, as  far as
the ligature, without occasioning any dis-
tension of its tunics.  He discovered, more-
over, that the blood no longer entered the
portion of the wounded vessel situated im-
mediately above the ligature, nor was the
quiescent state  of the small quantity al-
ready existing there in the slightest de-
gree disturbed, but  the whole of the  cir-
culating fluid was diverted into the col-
lateral channels.  After a short time, in-
deed, the blood collected above the liga-
ture was also carried away,  so that none
remained in that situation.  (Opera Mi-
nora.  I.  exp. 54.)  The same phenomena
were observed by Kaltenbrunner,  in his
experiments.  He found when he divided
the mesenteric artery of a frog, that after
the  blood had ceased  to  flow from  the
wound, it no longer traversed the portion
of the vessel  included between the seat
of injury and the nearest collateral branch,
although its lumen was  still open and
gaping.  The blood, when  it  arrived at
the origin of the collateral branches, was
deflected at an angle from the  calibre of
the  wounded vessel, into a  less obvious
route,  and  occasionally, when a few glo-
bules passed from the main current into
the empty vessel, they were  immediately
seen, like an accused criminal, making an
effort to return, and  unite themselves with
the  main current.  (Experimenta  circa
statim sanguinis et vasorum in inflam-
matione.  Monachii,  1826.  Also, Berard.
Diet, de Med.  IV.)  These facts have been
urged  as an argument  to prove that the
capillary vessels attract the blood through
the vessels which circulate it, and  it  has
been alleged,  that when an artery is di-
vided,  this  influence being no longer able
to act upon the blood through it but con-
tinuing to operate through the collateral
branches, that fluid is drawn on through
the latter, and that by these changes the
cessation  of  the hemorrhage from  the
bleeding artery is greatly facilitated. How
far any power of the capillaries is capable
of exercising such an agency has not been
satisfactorily shown, nor is it easy  to ex-
plain in  what manner they  attract  the
blood.  By many it has been affirmed, that
they possess an active  power  of expansi-
bility,  by which  a  vacuum is produced,
and that  this operates  on the blood  on
 (Wounds.)                         429

the  ordinary  principles  of  hydraulics.
Many arguments might be adduced to in-
validate this hypothesis, not the  least of
which is  the  well-known fact, that the
operation of an irritant upon a part, which
always produces an  increased determina-
tion of blood to the excited capillaries, in-
stead of giving rise to an expansibility of
those vessels, occasions them to contract.
Such expansibility, if it exist, would  be-
sides  operate as forcibly on the blood con-
tained in the smaller  veins, as  it does
upon that within the arteries.   It is well
known, that  Koch of Munich,  has been
for a long time in the habit of dispensing
with tieing the arteries after amputation.
   It is suggested by his son, that when an
artery is tied  or divided, the blood itself
possesses the faculty of selecting the  route
it should pursue—and that, therefore, it is
not astonishing, it should be capable by
some peculiar power or action, of avoiding
the open end of the divided artery. (Jour-
nal de Progres. III.; and Berard.  Diet.
de Med.  IV. 80.)  This conjecture  is too
destitute of every thing like a semblance
of probability to require examination. The
attractive power of the capillaries is, how-
ever,  so  fully proved by a mass of incon-
testable evidence, that it does not admit
of a doubt.  It is highly  probable, more-
over, that it exercises considerable  influ-
ence  upon the  cessation or continuance
of  hemorrhage  from  wounded  arteries.
The late  Professor Smith,  of Yale Col-
lege,  attributed  great power to this agen-
cy.  He supposed that the capillaries are
capable of exercising  a kind of pumping
influence  upon the blood, by which they
attract it through the  arteries, and that
one reason why hemorrhage  is  arrested
with  so much more  facility after amputa-
tion,  than from wounds of arteries when
the limb is not removed is, that in the lat-
ter case, this power of the capillaries con-
tinues to operate.  In corroboration of his
conclusions, he  adduces several cases of
amputation where no hemorrhage follow-
ed, notwithstanding the arteries remained
patulous and contained no coagula; and
to the same  end, we might  cite  numer-
ous facts recently mentioned by Guthrie,
where the bleeding ceased spontaneously,
even  though  the vessels projected  from
the stump.   Professor Smith also  men-
tions  the  cessation of bleeding from the
umbilical arteries of the child, as another
instance in which the hemorrhage ceases
in consequence of the attractive power of
the capillary vessels being cut off. (Surgi-
cal Memoirs. Edited by Nathan R. Smith.
p.  187.  Baltimore, 1831.) 
430
ARTERIES.  ("Wound*.)
   We feel well assured that  this power
of the capillaries is capable of exercising
considerable influence  in preventing the
cessation of hemorrhage from  wounded
arteries, when it continues to operate, as,
for example, when amputation is not per-
formed ; but we do not think that the fa-
culty itself is resident in any  vital ex-
pansibility or pumping  operation of these
vessels.   The blood itself being  vitalized,
a degree of vital affinity exists between
that fluid and  the vessels by which it is
circulated.  Whenever, therefore, the ca-
pillaries are stimulated,  they  seem to be
capable of attracting a greater quantity of
blood than usual, by virtue of the peculiar
relationship which exists between them
and their fluid contents. (See Capillaries.)
   <?.  Spontaneous  cessation  of hemor-
rhage from arteries which have been par-
tially  divided.  The occurrences which
take place when an artery of considerable
size is wounded, differ according to the
extent of the injury, its direction as re-
gards the axis  of the vessel, the relations
of the sheath with the  orifice, and other
contingent  circumstances.  Such wounds
may be  divided into longitudinal,  trans-
verse, and oblique; and in the last variety,
it will be important to consider them ac-
cording  as  one fourth or one third, one
half, or three fourths  of the vessel are di-
vided;  because when  the wound  is of
limited extent, the artery sometimes heals
without having its calibre obliterated; but
when it extends through three fourths, al-
though the  hemorrhage may cease  spon-
taneously, the  permeability of the vessel
is always destroyed.
   A longitudinal wound of an artery, of
the extent of three or four lines, does not
have its lips much separated.   John Bell
even  asserts, that "an  artery wounded
with  a small and slit-like wound, though
fairly cut, will yet preserve its pulse, and
will not  bleed;"  and Beclard  found in
his experiments, that when he  divested
the femoral artery of its sheath, and  made
a longitudinal cut in  it to the extent of
two or three lines, the  lips of the wound
were seen to be in contact during the di-
astole of the ventricle, but were separated
by a jet of blood during the systole.  Such
injuries,  however, are generally  attended
at first by considerable hemorrhage, and
this may continue until either syncope or
death takes  place.   But  if the  sheath of
the vessel be preserved,  the blood,  as it
flows  out, gradually insinuates itself be-
tween it and the artery, and forms a con-
siderable thrombus around the orifice;—
the stream  gradually becomes  smaller,
 and the puncture being finally closed by a
 mass of coagulum, the hemorrhage ceases
 entirely.   There  are generally two cir-
 cumstances connected with the infliction
 of the wound, favourable to the develop-
 ment of those conditions which are instru-
 mental in  suppressing  the  hemorrhage.
 The first is, that the cellular tissue com-
 posing the sheath consisting of loose and
 yielding filaments,  that structure is sel-
 dom divided to so great  an extent as the
 proper coats  of the artery.   The second
 is, the change of position to which the
 vessel  is necessarily exposed  under the
 influence of  the  impulse of the heart,
 which tends to destroy the parallelism be-
 tween  the  opening in its tunics, and that
 of the sheath.  Both these conditions are
 peculiarly favourable to the extravasation
 of the  blood  between the artery and its
 investment, where it immediately coagu-
 lates,  and plugs up  the orifice.   Hence it
 is, if the sheath be removed, and the ar-
 tery then wounded,  the animal will gene-
 rally bleed to death; but if the sheath be
 preserved, and is  merely wounded simul-
 taneously with the vessel, the hemorrhage
 will often cease spontaneously.
   The flow of blood  being  arrested, in-
 flammation soon supervenes.  Coagulable
 lymph is then deposited  in the  orifice of
 the vessel and in the adjacent tissues, the
 coagulated  blood  is gradually  absorbed,
 and the concrete  lymph forms  a kind of
 plug or excrescence, which completely
 closes the opening made in  the coats of
 the artery.  This is at first very conspicu-
 ous, but in process of time it is greatly di-
 minished in size, and if the vessel be ex-
 amined after the process of reparation has
 been completed, its  inner surface will ex-
 hibit merely a linear cicatrix, correspond-
 ing to the site of the wound.  This capa-
 bility of an artery to have a wound impli-
 cating only a portion of its diameter, heal-
 ed without destroying  its permeability,
 was known to Petit.   He presented to
 the  Academy of Sciences a  brachial ar-
 tery which had been wounded two months
 previously:  the lips of the wound were not
 united in immediate apposition,  but the
 opening was closed  by a plug which ad-
 hered  to  the  circumference.   This  new
 formation retained its integrity after being
 macerated in  water  for two  months, and
 in alcohol two years.
   Oblique wounds of arteries of limited
 extent do not differ materially from those
 which are longitudinal.   The lips of the
 wound, however, are more separated, and
the opening, owing to the elasticity of the
middle  coat,  assumes  the shape of an 
ARTERIES.  (Wounds.)
431
ellipsis or a crescent.  Such wounds al-
ways  bleed more  profusely  than  those
which are longitudinal.  This is a neces-
sary consequence of the gaping of the ori-
fice : still,  such injuries  are capable of
being closed without  the  obliteration of
the calibre of the vessel, by the formation
of a coagulum, first  between the latter
and its sheath, and afterwards  in the di-
vided orifice of the arterial tunics.   The
opening in the sheath here,  as  in longi-
tudinal wounds, is less extensive than that
in the proper coats of the artery, and the
gradual extravasation of  blood  destroys
the parallelism of the two apertures, and
thus impedes  the  egress of the blood
and  favours the formation of  a coagu-
lum by  which  it is finally  arrested.
The place of the coagulum is finally sup-
plied by coagulable lymph, which becomes
concrete and forms a solid plug or excres-
cence in the orifice of the vessel, and com-
pletely agglutinates it to the surrounding
parts.  If the artery be opened some time
afterwards, the portion of its inner  sur-
face corresponding to the  site  of the
wound, will present a small cicatrix  of a
lunated  figure. (Jones.  Op. Cit. p. 90.)
The spontaneous cessation of hemorrhage
from oblique  wounds will always  take
place with greater difficulty, in proportion
as the puncture or incision approaches the
transverse direction.
   Transverse  wounds of arteries which
do  not entirely sever the vessel, are far
more dangerous than either the longitudi-
nal or oblique.  This arises from the great-
er separation  of the lips  of the wound,
they being drawn  asunder by the elasti-
city of the vessel.  Owing  to  this,  such
wounds always assume a round figure—a
character of them which was long ago no-
ticed by Wiseman, Petit,  Monro, and
Haller.   It constantly occurred  in the
experiments made by Jones and Beclard,
except when one  half or more  of the ar-
tery was divided,  and has been well de-
lineated by Jules Cloquet.  (Surgical
Pathology. PI. I.  fig. 1.)
   When an artery of large  size receives
a puncture or  cut  severing  its tunics  to
the extent of  one fourth  or  one third of
its  diameter,  blood is at first projected
from the wound presenting  the ordinary
characters of arterial hemorrhage, and if
no  attempt  be made to arrest it the
bleeding may continue until syncope takes
place, or until the animal dies  from the
lose of blood.  This  will always happen
when  the  sheath  of the vessel is de-
stroyed ; but if it should be preserved, in-
asmuch as the  opening in it seldom gapes
to the same  extent as that in the proper
tunics of the artery, the blood will gradu-
ally become insinuated between it and the
vessel, to a considerable extent above and
below the puncture.  This will destroy the
coincidence between the  opening in the
sheath and that of the artery;  the blood
will  thus  meet with a still greater obsta-
cle to its escape—a more extensive co-
agulum will be formed, which will finally
perfect the closure of the  orifice, and pre-
vent the further escape of blood. Inflam-
mation will soon after ensue, coagulable
lymph will be poured  out, and  after the
coagulum has been removed by absorp-
tion, a firm accretion of organized lymph
will  be found,  closing the orifice of the
artery and  agglutinating the   adjacent
parts.  Under these circumstances,  the
wound of the vessel is repaired without
destroying its permeability, but  the  cica-
trix  which remains is always larger on
the  inner  side  of the artery than that
which  follows  either a  longitudinal or
transverse wound.
   Should half the diameter of the vessel
be divided, a profuse hemorrhage will en-
sue,  and continue almost invariably until
death  takes  place,  unless  arrested  mo-
mentarily by syncope; and even then, as
soon as the powers of life are resuscitated,
the bleeding is renewed, and leads eventu-
ally  to a fatal termination. This is owing
to the great separation of the lips of the
wound, occasioned by the  retraction of
the  divided  portion of the  elastic  coat,
which keeps the opening so patulous, that
the  blood continuing to sweep  along the
vessel, a coagulum of sufficient extent and
firmness to close it cannot be formed. Be-
clard found in his experiments, that all
wounds implicating half  the diameter of
an artery were fatal  from  loss  of blood,
and  the same results  have been obtained
by others who have instituted similar in-
vestigations.   Professor N. R. Smith very
properly remarks, in reference to such ac-
cidents,—" if it be true that the  capillary
vessels and  the arteries  themselves, are
capable of influencing the current of blood
along the vessel, it is obvious that the flow
of it must be rendered much more impe-
tuous than when  the capillaries are en-
tirely cut off from  continuity with their
trunk, and will therefore very  much in-
terfere with the  recuperative   process."
(Surgical Anatomy of the Arteries.  2d
edit p. 19.  Bait 1835.)   It is possible,
however,  for hemorrhage to cease from
wounds of this  kind, notwithstanding all
these opposing  circumstances.   Such an
event is  nevertheless  exceedingly rare, 
432                         ARTERIES.  (Wounds.)
and can never occur except by the forma-
tion of a large coagulum during protracted
syncope, or under  some favourable con-
currence of circumstances; nor can a cure
be effected but by the total obliteration of
the wounded portion of the vessel.
  It may have the semblance of a paradox
to assert, that a wound implicating three
fourths of the diameter of an artery is less
formidable, as regards hemorrhage, than
one only dividing  one  half its extent.
Such  a conclusion is nevertheless  fully
supported by  the experiments of Jones
and Beclard. The reason is perfectly in-
telligible, when the  changes  the vessel
undergoes  on the receipt  of the wound
are examined.  Owing to its great elasti-
city, and its disposition to retract as scon
as two thirds or three fourths of its diam-
eter are severed, the lips of the wound
are drawn widely asunder, and the undi-
vided portion is  put upon the stretch and
elongated,  so as to impart  to the vessel
the scolloped  or  beaked appearance of a
pen, or the bevelled figure of the  mouth-
piece of a clarionet.   A profuse  hemor-
rhage follows the infliction of the wound,
but inasmuch as the proper coats of the
artery retract more than the sheath, the
divided portion of the latter slightly over-
laps the edge of the former, so that the
diameter of the artery being diminished
immediately  above the divided point by
the peculiar nature of its retraction, a co-
agulum is soon formed both exteriorly and
within the vessel, by which a temporary
cessation of the hemorrhage is secured.
Inflammation then supervenes; coagulable
lymph is deposited  both internally and ex-
ternally, and in proportion as  the coagu-
lum  is removed,  this becomes consoli-
dated, and completes the obliteration of
the vessel, precisely as it takes place when
it is  entirely divided.   It  should be  re-
marked, however,  that before this  is ef-
fected,  the small portion which was not
severed, is generally destroyed by ulcera-
tion,  and allows the artery above  and be-
low the wound to retract more extensively
than  it would otherwise be capable of do-
ing.  In all cases,  after the plastic lymph
has sealed up the vessel, or the opening
made through its coats, if there should be
either ulceration or suppuration, granula-
tions  are formed, and the part is cicatrized
precisely as in other wounds.
   These principles have been chiefly de-
duced from experiments on animals, and
although they are to  a certain extent ap-
plicable to the  human subject they are
not sufficiently so to  justify a reliance on
the powers  enumerated in  cases of pro-
fuse hemorrhage  from  a large artery.
There  is, indeed,  a very material differ-
ence between the  properties  of the arte-
ries of animals, and of those of man.  In
the former, they are more elastic and pro-
bably more contractile; and in addition to
this, the blood of animals coagulates more
readily; so that by the concurrent agency
of these causes, hemorrhage from their
vessels is arrested with greater facility by
the spontaneous changes detailed above.
Still, it has been shown that  under many
circumstances, these acts are adequate,
even in the  human subject, to effect  the
suppression of hemorrhage from wounded
arteries.  There are, however, some cir-
cumstances which  will render such a re-
sult difficult  or even impossible. Arteries
traversing bones—those  which are firmly
tied down by a strong aponeurotic sheath,
or course through a texture so dense as to
fix them firmly in their situation, and such
as run upon the boundary of some of the
natural cavities, or so closely beneath the
skin as to possess  a very slight covering,
are more unfavourable  for the develop-
ment of those changes by which hemor-
rhage is suppressed.   They are either un-
able to retract  or owing to the character
of the  surrounding parts, an external co-
agulum cannot readily form, and they are
thus deprived of two of the  most impor-
tant conditions  usually  concerned in ar-
resting the flow of blood.  The condition
of  the  blood  itself also  exercises a very
important influence on the process. When
the individual is robust and his blood rich
in fibrine and albumen, it coagulates more
promptly and firmly, and favours the ces-
sation  of the bleeding; but when that
fluid is thin  and  watery, possessing but
little crassis, only a slight and very loose
coagulum can be developed, altogether too
feeble   to prevent it  escaping from the
wounded  artery.  This  condition of the
fluid may be generated either by previous
disease,  or  by repeated hemorrhage;  a
preternatural loss  of blood always tending
to render that which  remains much more
watery than  it is in health. Under either
of these circumstances,  it rarely happens
that the  hemorrhage  ceases spontane-
ously;  but  far  more frequently  it con-
tinues until  life is destroyed by the loss
of blood.   In many cases, moreover, even
when  the hemorrhage has been tempora-
rily arrested, the barrier set  up by nature
yields to the natural impulse of the cir-
culation,  or it is broken up by some  sod-
den or imprudent  movement of the body,
and consecutive  bleeding  takes  place,
which  may  either cease spontaneously, 
ARTERIES. (Wounds.)
433
and recur again and again, until life  is
destroyed, or it may continue without in-
terruption to the same termination.   This
hemorrhage  may  take  place either  from
the upper or lower end  of the vessel, and
without any very important  change  of
texture in the artery  or the  coagulum.
Very often, however, it is a consequence
of the  development of  suppuration or ul-
ceration  in  the wound,  which tends  to
break up the connexions previously estab-
lished  by the  coagulum  and  the plastic
lymph poured out by the inflamed vessels.
In many cases  the hemorrhage seems  to
be excited by the development of too much
irritation in the wound, creating a preter-
natural determination of blood to the  part;
and our own experience fully corroborates
a remark made by Professor N. R. Smith
—that the presence of the external coagu-
lum is occasionally sufficient to produce
this effect. (Op. Cit. p. 20.)
  In animals,  the  plasticity of the blood,
and the recuperative powers of the  arte-
ries, are so  great that wounds affecting
them  are not  generally followed by the
formation  of aneurism.  It is often the re-
verse  in  the human subject   It has been
fully demonstrated  by  Petit,  Beclard,
and others, that wounds  affecting only a
small extent of the diameter of an artery
in man may heal spontaneously, without
giving rise to  aneurism.  But it happens
far oftener that this fortunate termination
is not secured.   Should the external open-
ing be  very narrow, or not correspond ac-
curately with  the  wound in  the artery,
the blood, instead of escaping, may be
driven  extensively into the surrounding
parts, and the orifice of the  vessel not be-
ing closed,  a  primitive  false  aneurism
will be the consequence.  And  should the
opening in the  artery be closed for a time
by a fibrinous  concretion and  coagulable
lymph, the obstacle thus formed  may be
too feeble to sustain the impulse of the
blood after the  vigour of the circulation is
restored.   Under these circumstances, the
wound in the sheath and the cellular coat
being more perfectly united by coagulable
lymph than the other tunics, they may be-
come gradually dilated into an aneurismal
sac, constituting what  is called consecu-
tive false aneurism. (See Aneurism.)  It
should  be remarked, however, that this
can never take place when more than one
half the diameter of the artery is divided,
or where  it  is completely severed,  since
in all such cases, the calibre of the vessel
is always obliterated.  For an account  of
the changes which ensue, when a wound
is  inflicted simultaneously  on  an artery
   vol. ii.         37
and a vein, we must refer to the article
Varicose Aneurism.
  3. Lacerated wounds of arteries. These
injuries, like those inflicted by puncturing
and cutting instruments, may involve the
whole  of the  coats of an  artery, all of
them  being torn  through, or they may
be confined to the internal coat or to it
and the middle tunic.  Such wounds may
be produced by a preternatural longitudi-
nal distension  or elongation  of the vessel,
as, for example, in violent efforts  to  re-
duce dislocations;. by one of the extremi-
ties becoming  entangled in a piece of ma-
chinery, &c.;  or they may be inflicted by
gun-shot or any obtuse body propelled with
sufficient force to produce a laceration of
the soft  parts. Lacerated wounds  of ar-
teries  may likewise  be  produced by the
sharp end or spiculje  of a fractured bone,
and when they are previously diseased, by
any violent effort of a  kind  to put them
preternaturally upon the stretch.
  If an artery be  elongated  with  consi-
derable force, but  still with less violence
than is necessary to tear it asunder, the
internal coat being incapable of yielding
to as great an extent as the other, will be
torn at various points, and  if the inner
surface of an  artery which has been thus
treated be examined, it will present nu-
merous fissures  extending  through the
lining membrane, and ranging at intervals
partially or completely round the vessel.
These cracks or fissures are sometimes
closely crowded together, and all of them
range  transversely as regards the axis of
the artery. They render its inner surface
rough and uneven,  and form so many mi-
nute valves or crevices, in which the blood
becomes  insinuated  and coagulates.   A
small nucleus of coagulum being formed
in this manner in each rent, a considera-
ble impediment is  occasioned to the free
transmission of the blood through the ves-
sel, and  as the rudimentary coaguli con-
tinually increase in size by gradual  accre-
tion, if the artery be one of" moderate di-
mensions, it will by this process be  finally
filled up, and completely obliterated.  In
some cases, the insinuation of the blood
beneath the edges  of the lacerated mem-
brane may dissect it up for some distance,
and  so far weaken the fibrous coat, as to
lay the foundation of aneurism.  This will
be more  particularly apt to occur when
the injured vessel  is one of large size.
   If the  extending force be  carried still
farther, not only the lining membrane, but
the fibrous coat also will be lacerated.   It
may be  torn  at one or at several  points,
and the rents  may be confined to a portion 
434                         ARTERIES.  (Wounds.)
of the circumference of the vessel only,
or extend entirely  round  it,  each one
ranging in nearly a circular direction, or
parallel with the fibres.  Here nearly the
same changes will take place as  in the
preceding case.  Each laceration will form
a kind of valve in which  the  blood will
insinuate  itself and become coagulated,
and  the vessel may  either  be  obstructed
or obliterated, or the cellular coat will be-
come dilated into an aneurismal sac.  The
latter occurrence  will  take place much
oftener, however, than when  the lining
membrane alone is affected, and the great
liability of those arteries which are situ-
ated in the vicinity of movable articula-
tions, to aneurism, as, for example, the
popliteal, may be explained upon this prin-
ciple;—their coats being previously dis-
eased, the fibrous and internal tunics will
be apt to become lacerated under the ex-
tending force occasioned  by the motions
of the joint,  and an aneurismal  tumour
will  be produced by the dilatation  of the
cellular coat.
  Finally, the whole  of the arterial tu-
nics  may  be lacerated, the  vessel being
torn  completely across.  Under such cir-
cumstances, if the artery be entirely free
from any close and unyielding adhesions
with a part which is fixed and immovable,
the two internal tunics give way  before
the external,  and the  latter,  possessing
great extensibility, will have its filament-
ous tissue very much elongated before  it
lacerates,  and will be drawn out consider-
ably beyond the severed ends of the fibrous
and internal coats, assuming at the same
time the  appearance of two cones, the
points  of which look towards each other,
while their base corresponds to the upper
and lower end of the divided vessel.  Bom-
pard found in his experiments, that when
very large arteries, as the carotid and the
crural, are lacerated, the cellular coat ex-
tends and tears irregularly into thin shreds
of greater or less length.  The two inter-
nal coats are torn without presenting, to
any extent at least, the circular retraction
which produces the complete  or incom-
plete obstruction of the canal.  In the ar-
teries of middle calibre, as  the brachial,
radial, cubital, or tibial, two kinds  of phe-
nomena are  observed:  one,  depending
upon the modifications which the external
or cellular tunic undergoes; and the other,
upon the alterations of the internal coats.
The external coat, thus, by degrees, drawn
and elongated, presents a hollow cone, the
base of which  corresponds with a point a
little above where the  internal coats are
ruptured,  and the  summit prolongs  itself
into a long slender filament;  the shape is
happily enough compared with the slender
cone made by  drawing out a glass tube
whilst heated in the flame of a lamp.  By
the inflation of an artery thus treated, the
cellular prolongation is distended into a
small,  conical,  semitransparent bladder,
impervious to the air, unless  the inflation
has been forcibly made. The internal and
middle coats-are torn circularly, but not
in a clean manner,  having frequently the
appearance  of small incomplete rings,
which are entangled  and carried  along
with the distended cellular tissue.  More-
over,  these two coats exhibit, near the
point where they have been torn, parallel
ridges, forming folds in the axis of the ar-
tery, having their base towards the rup-
tured edges of the vessel, thus contribut-
ing to diminish its calibre.  (Jules Clo-
quet.  Surgical Pathology,  p. 99.  PI. I.
figs. 7 and 8.)  Nearly the same resulta
were obtained by Beclard, and more re-
cently by  N. R. Smith, as well as several
others who have investigated the subject
experimentally.
   It  nevertheless   happens  sometimes,
when  the  artery is  closely adherent to
some  solid unyielding body,  as the head
of the humerus in dislocations of that
bone,  that the cellular tunic,  in the act of
being torn, is not so much elongated,  but
severs nearly on the same level with tin
rupture of the  internal and  middle coat.
In such cases,  life is generally destroyed
by  hemorrhage,  the  blood being exten-
sively  extravasated into the surrounding
parts.  This  accident happened twice to
Professor  Gibson of Philadelphia, in at-
tempting to reduce  ancient dislocations of
the humerus.   The artery had contracted
intimate adhesions with the displaced head
of the bone, and was torn across in making
the extension which was necessary to ef-
fect the  reduction.   The  records of the
science contain  other instances of  the
same  kind, and as  lacerated arteries un-
der other circumstances seldom bleed to a
dangerous extent, there must be some pe-
culiarity  in these cases, which interferes
with those changes by which hemorrhage
is arrested spontaneously.
   The remarkable  immunity of most la-
cerated wounds from hemorrhage,  even
when very large arteries have been torn
across, has long been known to surgeons.
In cases  in which the arm has been forci-
bly severed from the trunk, by becoming
entangled  in machinery, or the leg has
been  torn across by a similar accident
little or no bleeding has followed, and the
individuals have recovered  without the 
ARTERIES. (Wounds.)
435
necessity of tying the arteries.  The case
reported by Cheselden, of a miller, who
had his arm  torn from the body in  this
way, and those which have been published
by La Motte, Carmichael, Mussev, and
others, where a similar  accident occurred,
afford a  striking  exemplification of this
truth. The same character, likewise, per-
tains to gun-shot wounds,—in short to all
injuries in which  the arteries have their
tunics torn asunder,  either by obtuse bo-
dies which contuse them violently, or by
preternatural elongation or distension.
   This being the case,  it is important to
know, why  it is  that  lacerated arteries
seldom bleed.  Various explanations have
been  offered,  but unfortunately most of
them are so'  contradictory, or so little sa-
tisfactory, that the  question is still  sur-
rounded by numerous difficulties. By many
it has been affirmed, that arteries do not
bleed under such circumstances, because
they are stunned  or  paralyzed by the in-
 jury, so as to be incapable of contracting
and forcing out the blood.  Jones thought
that the hemorrhage is arrested in nearly
the same manner as in punctured or in-
 cised wounds of the arteries. Sir Charles
 Bell affirms, that when the arm is drawn
 off by machinery, or  torn  off by round
 shot,  and the artery lies exposed, hemor-
 rhage  does  not take place,  because the
 coats of the vessel are killed or injured,
 and being,  in consequence of this, no
 longer able  to preserve the blood fluid, it
 coagulates within the mouth of the artery
 and stops the bleeding.  He maintains,
 that whenever the proper relation between
 the coats of the vessel and the blood is in-
 terrupted, that fluid immediately coagu-
 lates, and this he assigns  as a reason for
 the arteries being obstructed by coagula
 in a mortified part,  and for the develop-
 ment of lamellated fibrinous concretions
 in large aneurisms.  (Principles of Sur-
 gery.  By John Bell :  with Commenta-
 ries by Charles Bell.  I.  271.  London,
 1826.)   By many, the  absence of hemor-
 rhage has been attributed to the violent
 shock sustained by  the nervous system,
 which is also felt by the heart and arte-
 ries,  and renders their action  so feeble
 that a coagulum is allowed to form in the
 bleeding vessel, before the powers of the
 circulation rally sufficiently to propel the
 blood from the wound.  A more rational
 explanation   is that given by  Beclard,
 Syme, N. R. Smith, and  several others,
 who have investigated the subject with
attention.  They think,  that  in conse-
quence of the cellular coat being the last
to give way, it is elongated, as described
above, beyond the line of rupture of the
internal and middle tunics, and forms a
conical prolongation either closed or rag-
ged at its  extremity, which prevents the
blood  from  escaping, or favours its coagu-
lation, so as to close the extremity of the
artery.  This conjecture is strongly cor-
roborated by the account of such injuries
already given,  and  is proved  by a fact
mentioned  by Berard.  He states, that
an individual was admitted at the Hopital
St. Antoine  on account  of a contused
wound, at the bottom of which the ulnar
artery could be seen completely torn asun-
der.   Not  the  slightest hemorrhage had
taken place; but when a very small por-
tion was clipped from the upper and lower
extremities of the wounded vessel with a
pair of scissors, a jet of arterial blood im-
mediately  took place from the  wound.
(Diet, de Med. IV. 97.)   But in addition
to the agency  performed by the conical
prolongation of the cellular coat in  re-
straining  the blood, and  favouring  the
formation of a coagulum within, it is very
properly  observed  by Professor N.  R.
Smith, that the internal coat is fractured
transversely at numerous places, so as to
present an indefinite number of small  fis-
sures, into which the blood of the artery
is injected.  Blood  also probably flows
from the ruptured tissue into these fissures,
and there commingles with that received
from  the  cavity of the vessel.   Coagula-
tion then takes place at these points, com-
mencing first in the  cracks of the inter-
nal coat, which being rough and uneven,
form  a favourable  arrangement  for their
firm attachment to the walls of the artery,
and prevent them from being dislodged by
the impulse of the circulating blood. (Sur-
gical Anat. of the Arteries. 2d edit. p. 24.)
These  rudimentary  coagula  being once
formed and firmly attached to the lace-
rated surface of the vessel, and the blood
not  being  able to escape  with freedom
from the  wound, in consequence of  the
 end  of the artery being closed by  the
 conical prolongation of the cellular sheath,
 the process of coagulation proceeds more
 rapidly, until finally an elongated mass is
 formed, filling up  the calibre  of the ves-
 sel for some distance, and having its nu-
 merous radicles firmly implanted in  the
 fissures of the lacerated lining membrane.
 The deposition of coagulable  lymph,  and
 the subsequent coalescence of the artery,
 are effected by the same changes as in in-
 cised or punctured wounds.
   But notwithstanding lacerated wounds
 do not generally bleed, it must not be(in-
 ferred  that they always possess this char- 
436                         ARTERIES.  (Wounds.)
acter.  It too often happens, on the con-
trary, that the wounded on the field of
battle  are lost by profuse hemorrhage
taking place  from such injuries, and even
though there may  be  no bleeding at the
time the wound is inflicted, the surgeon
should never suffer himself to be lulled
into a fatal security;  for experience has
fully  proved, that  such wounds are  re-
markably prone to  give rise to secondary
hemorrhage.  The condition of  the parts
at the time, it has been shown,  is highly
favourable to repress the  flow of blood;
but the barrier thus built up is  only pro-
visional ;  it can only prove efficient for a
limited period, and as the vital powers of
the vessel, and of the  adjacent structures,
are often too much impaired by the vio-
lence  inflicted  upon  them, to  allow  of
their accomplishing  the perfect closure
and obliteration of the wounded artery, it
frequently happens, that when the slough-
ing, which is consequent upon such a con-
dition, takes place, the coagulum is  dis-
lodged from the orifice, and gives rise to
fatal hemorrhage.
   4.  Simple contusions of arteries, with-
out any perceptible solution of continuity
of their tunics, do  not always give rise to
 the same consequences. It often happens,
 when a ball or a  cannon-shot has passed
 in the vicinity of an artery of consider-
 able size, that no bad  consequences, so far
 as the vessel is concerned,  ensue for seve-
 ral days.   But when the sloughs begin  to
 separate, if the arterial tunics have been
 severely  contused, they are apt to give
 way, and occasion  a fatal hemorrhage, un-
 less the  surgeon should be prompt in re-
 straining it by proper means.  The reason
 of this is, that the injury inflicted upon the
 artery so far destroys its vital powers, as
 to render it incapable of sustaining the in-
 tegrity of its structures.  Its tissues there-
 fore become inflamed;  they are rendered
 soft and  brittle, and  when the vitality of
 the surrounding parts is  destroyed,  and
 they slough away, the artery also yields,
 and pours out blood with  a freedom  pro-
 portionate to its magnitude.  In some in-
 stances, however,  a very different conse-
 quence ensues.  The coats of the artery
 are not destroyed by sloughing, but the
 violent contusion so far impairs its vitality,
 that the blood within coagulates and closes
 its calibre,  or  inflammation takes place,
 and the obliteration is  completed by the
 conjoint influence of the  effusion of co-
 agulable lymph, and  the solidification of
 the blood, precisely as it is accomplished
 in cases of arteritis  arising  from other
 causes.   It  sometimes  happens,  indeed,
that both the artery and its corresponding
vein are obliterated from this cause; and
it has been shown by Guthrie, that when
this takes place,  gangrene is very apt to
ensue.  It has been observed,  moreover,
that the same consequence very generally
follows wounds severing both  the artery
and vein, gangrene being much more apt
to take place in such cases, than when the
artery alone is divided.
   The consequences of wounds of the ar-
teries, both immediate  and remote, have
been  so fully mentioned in the course of
the preceding observations,  that it cannot
be necessary to recur  to  them  in this
place.  The mere division of an artery
even  of large size, were  it not  for  the
consequences involved in a profuse loss of
the vital fluid, would be an accident of
but little importance.  It is this, together
with  the effects which follow, that consti-
tutes  the  chief  danger of such injuries,
because  these vessels, unlike the veins, do
not so readily take  on inflammation in
consequence  of violence  inflicted upon
them.  It may  happen, notwithstanding
the conservative powers of nature, which
often  prove  so  competent  to  arrest the
bleeding, that life may be destroyed either
by the profuse flow of blood externally, or
its extravasation into the tissues or one
of the natural cavities.  Aneurism is an-
other consequence which  may follow  a
wound inflicted upon an artery; and  if a
vein  be wounded  at  the  same  time, if
there be a correspondence  between the
openings in  the two vessels,  the artery
may  project  its  blood into the vein, and
give  rise  to  varicose aneurism.  It hap-
pens, moreover, when the main artery of
a limb is wounded, that the parts thus de-
 prived of their proper supply of blood, be-
come numb, cold,  and  devoid  of circula-
tion ;  and if the collateral vessels should
not soon become sufficiently free to supply
 the structures with their due supply of
 the .vital fluid,  they  will  sooner  or later
fall into gangrene. (See Obstruction.) For
an account of the manner in which the
circulation is restored when  a principal
artery has been wounded, we  must refer
 to the articles Ligature and Capillaries.
   A  knowledge  of the  fact that  the un-
 assisted powers  of nature  are  often com-
 petent to arrest the bleeding from a wound-
 ed artery, should not beget a too confident
 reliance  on  her resources.   They  will
 often fail even  under favourable  circum-
 stances, and if  the surgeon should trust
 too far  to the powers  of the  system,  he
 will often experience the mortification  of
disappointment  and will  find in  many 
ARTERIES. (Wounds—their Treatment.)
437
cases where the hemorrhage has been ar-
rested temporarily by the means described
above, that  after a short  time, the safe-
guard set up by nature will be broken
down by the impulse  of the circulation,
or by changes taking place in the wound,
and  his patient will be destroyed by he-
morrhage, unless he should be present to
command it by artificial means.
   Treatment.   The  preceding  observa-
tions show, that  the unassisted efforts of
nature are  sometimes  adequate to arrest
the  flow of blood from wounded arteries.
These observations are also important as
indicating the manner in which the bleed-
ing  is  arrested,  thus furnishing  useful
hints to the  surgeon in the application of
such means  as may be  found necessary to
fulfil the same end.  They are indeed
chiefly valuable on this account; for not-
withstanding  hemorrhage  occasionally
ceases spontaneously, it would seldom be
safe, when a vessel of considerable size
has been wounded, to confide in the unas-
sisted resources of the  system.
   The treatment proper to be employed
for the purpose of arresting hemorrhage
from  wounded  arteries, may be  divided
into provisional or temporary, and those,
the  operation  of which  is  permanent.
They may,  besides, be divided into those
which prevent the flow of blood from the
wound by compressing  the injured artery
between the seat  of injury and the heart,
and  those which act directly upon the
wound itself. The second class of means
may be subdivided as follows:  1.  Those
remedies which promote the contraction
and retraction of the orifice of the artery,
and thus favour the formation of a coagu-
lum.  2. Those which close the mouth of
the divided  artery.   3. Compression of
the bleeding vessel in the wound itself
4. Those means which effect the oblitera-
tion  of the  vessel by inducing adhesive
inflammation.
   Under the first head we have  a variety
of resources,  all  of which  operate  upon
one general  principle—that of compress-
ing the injured vessel at some  point  be-
tween the  wound and  the  heart.  The
principal means of this kind are pressure
maintained upon the course of the artery
by the finger or thumb,—or a variety of
mechanical  contrivances, as  the tourni-
quet, torcular, artery compressors  of dif-
ferent  construction,  the  compress  and
bandage,  and other powers  that  can be
rendered available in arresting the course
of the  blood  along  the wounded artery.
Such  remedies  are  generally resorted to
in cases of emergency, and  are  seldom
                  37*
employed except  as provisional means, to
command the flow of blood until those
whose  influence  is  permanent,  can  be
adopted.   For this purpose, they are ex-
ceedingly valuable, but unfortunately they
cannot ,in general be  long continued, as
they are  apt to destroy the vitality of the
limb by cutting off its  supply of blood, or
to give rise  to other mischievous conse-
quences of a character to render the long-
continued use  of them prejudicial  and
highly improper.
  The advantages to  be  derived  from
pressure  made with the finger  or  thumb,
will depend very  much upon the situation
of the vessel to which the force  is applied.
There  are many arteries  even of large
size, so superficially situated,  and placed
so immediately over bones  or other  solid
points  of resistance, that pressure can be
easily made upon them, so as to command
the most alarming hemorrhage.  Such are
the arteries  of the  head, the subclavian,
brachial,  crural,  femoral,  and  even the
common  carotid.  The same may be said
of the  radial and ulnar, the palmar arch,
and the  anterior tibial, where  it courses
along the anterior part of the ankle,  and
after it takes the  name of dorsal artery of
the foot.   But when an  artery is  deeply
embedded in soft  parts, and is destitute of
a solid point  of support, the force of the
pressure  will be so far lost, as to render it
too feeble a resource to deserve attention
when the bleeding is profuse.  The asser-
tion made  by John Bell relative to the
impracticability of commanding  the course
of the  blood through the large arteries by
pressure,  has been  contradicted  by the
concurrent experience of all surgeons of
the present day, and a majority  of the best
operators feel so secure in this procedure,
that they seldom use the tourniquet during
the operation of  amputation.   It will be
useful, therefore,  to describe the best me-
thod of making pressure upon the princi-
pal arteries,  either for the  purpose of ar-
resting the flow  of blood  from a  wound
accidentally  inflicted, or during amputa-
tion.
  Compression of the common carotid ar-
tery.  From the deep situation of this ves-
sel,  and  its  intimate  relations  with the
pneumo-gastric and  sympathetic nerves,
and the internal jugular vein, it cannot be
so easily compressed as the subclavian ar-
tery.   Yet in cases of alarming  hemor-
rhage, pressure may be so directed as to
command the flow of blood until  a  liga-
ture is  applied.   The  head  should  be
thrown forcibly backward,  and  the thumb
of one  hand,  a common seal mounted on a 
438
ARTERIES.  (Wounds—their Treatment.)
handle,  or a key wrapped with soft linen,
fixed upon the course of the vessel on the
inner side of the sterno-cleido-mastoideus
muscle, while the other thumb is placed
on the  outer side.   The pressure should
then be directed backwards, so as to com-
press the artery against the anterior face
of the vertebral column.  This operation
is, however, always painful,  because of
the pressure  on the nerves, and the con-
striction of the trachea, and  cannot be
long endured.
   Compression of the subclavian artery.
This may be  effected at  four  different
points;  but the most convenient and se-
cure is, above the  clavicle, where the ves-
sel is passing over the first rib, and from
between the scaleni muscles.   The pa-
tient may be either placed upon a low seat
or in a recumbent  posture.   The arm
should be drawn  downward and forward,
and the head inclined to the opposite side.
A triangular space will be observed, bound-
ed anteriorly by the  sterno-cleido-mastoid-
eus  muscle, posteriorly by the trapezius,
and inferiorly by the clavicle. The thumb,
or instrument used for compression, should
be placed upon  the  internal and inferior
part of this space, just  on  the outer side
of  the   sterno-cleido-mastoideus muscle,
where  the artery will be felt emerging
from between  the scaleni  muscles,  and
sweeping over the  first rib.   By direct-
ing the  force downward, backwards, and
slightly inwards, the vessel can be  easily
commanded.
   Camper recommended the shoulder to
be pushed forcibly  backwards,  and the
pressure to be applied in the triangular
space between the clavicle, coracoid pro-
cess, and the upper border of the pectoral
muscle.   But this method  will be found
more difficult of execution,  and less  ef-
fectual, than that just described.  The ar-
tery may also be compressed in the axilla,
against the head of  the humerus.
   Compression  of the crural  artery can
be easily accomplished at  the  point at
which it escapes from the  abdomen over
the horizontal  branch of the  pubis, and
beneath Poupart's  ligament.   At this
point it will be  found midway  between
the  anterior superior spinous  process of
the ilium and the  symphysis of the pubis,
where  it reposes upon  the front  of the
bone.   The individual  should be placed
upon a table, on  his back, in order that
the pelvis may have a fixed point of sup-
port,—and the leg  should  be extended.
The thumb is then to be  fixed upon the
vessel at the  point  designated, and com-
pressed  firmly against  the  horizontal
branch of the pubis.   This can be easily
accomplished  in lean subjects, and even
in those who are  corpulent it is not at-
tended with difficulty.
   Pressure  made  upon any one of these
great vessels will  of course command he-
morrhage from any of the branches given
off by them.  But their ternary and qua-
ternary divisions  may  likewise be com-
pressed in various  situations, where there
is a solid point against which the pressure
may be made.  But after what has been
said, the method of doing this requires no
particular description.
   The same ends  may be obtained by the
common tourniquet (q. v.), or when that
instrument  is not at hand, by a common
handkerchief tied around  the limb, and
then twisted by thrusting the end of a stick
beneath it. It will be useful before applying
the bandage, to place a graduated compress
or roll of linen over the vessel, and to ad-
just a flat piece of horn, wood, or leather,
beneath the handkerchief, in order to pre-
vent it from pinching the skin where it is
twisted with the stick.   Neither of these
means,  however,  admits of more  than a
temporary employment for the purpose of
commanding the flow of blood until other
■expedients  can be adopted,  inasmuch as
by the constriction of the  entire circum-
ference of the limb,  they completely ob-
struct the circulation,  and if long conti-
nued, will  become  exceedingly painful,
and finally give rise to  great tumefaction
and gangrene.  The compress and band-
age may be employed  for the same pur-
pose, but it is equally objectionable.  A
piece of 6oft linen or of some other mate-
rial should be folded so as to  form  a cone
of proper size, the apex of which should
then be fixed  upon the  course of the ves-
sel, and  confined by several  turns of a
roller bandage, thrown around the mem-
ber with a degree  of constricting force
sufficient to interrupt the passage of the
blood through the  artery.
   A very simple  expedient may be sub-
stituted  for all these, which is not liable
to the same serious objections, because the
force  only operates upon two opposite
points of the limb, and leaves nearly the
whole  of the collateral  circulation free
and unobstructed.   A graduated compress
is first placed over the vessel, and four or
five folds of soft linen  along the opposite
side of the limb.  Over each of these, a
flat piece of board of five or six inches in
length, and about  two inches broader than
the diameter of the limb, is to be placed,
—the one before, and the other  behind.
The  strap  of  a  common tourniquet  is 
ARTERIES. (Wounds—ilveir Treatment.)
439
buckled over these and around the limb,
and the screw of the instrument turned so
as to produce the requisite degree of com-
pression upon the course of the artery.
As but little force is generally required to
command the flow of blood along the ves-
sel  when  the  apparatus is  properly  ad-
justed, this procedure may sometimes be
continued  until the wounded vessel  be-
comes closed or obliterated.  It should not
be used to the  exclusion of the ligature,
or other safer and more effectual means;
but  under some circumstances, when  it
has  been  found difficult to  secure  the
bleeding artery, we have employed it with
perfect success.  Sir Charles Bell men-
tions a somewhat similar expedient which
he  adopted successfully to compress  tlie
dorsal artery of the  foot   A graduated
compress was placed upon the artery,  and
two flat sticks, eight inches in length,  and
an  inch in breadth, were disposed trans-
versely—the  one  across the  instep,  the
other across the sole of the foot the ends
of which were tied together, so as to keep
up  the necessary  degree of compression
until tlie wounded vessel ceased to bleed.
Either of these plans may  be  adopted
whenever  it  becomes  requisite to com-
press any  of the arteries of the upper or
lower extremity, and  they will be found
applicable  to the hand or foot,  and to  any
part of either  the  leg,  thigh, or arm.
Great precaution must  be observed, how-
ever, to have the  graduated compress of
proper size and shape, and not to use more
force than  is sufficient to prevent the flow
of blood; otherwise great pain and tume-
faction will be experienced, and gangrene
may ensue.
  A variety of artery  compressors have
been devised, and some of them may be
employed  with advantage  (see Tourni-
quet) ; but in no case should any of them
be relied on to the exclusion of more im-
portant means.
  The chief reliance  must be placed on
the second class of means, or those which
exert their influence on the orifice of the
wounded vessel.  The best applications to
promote the retraction and contraction of
the end of the divided artery are
  Refrigerants and Styptics.  The  effi-
cacy of cold in arresting hemorrhage is
well known.   Very often, when the bleed-
ing takes place from vessels of small size,
the simple exposure  of the wound to the
cool air will arrest the flow of blood. Cold
water, ice, or snow, applied, to the part
will  frequently exercise a  prompt influ-
ence in  this way, and it is often observed
after operations, that even arteries of such
size  as to throw out blood with consider-
able  volume,  cease to bleed soon after
sponging the wound with cold water. But
however prompt the agency of cold may
be, it can only be  relied on when the he-
morrhage proceeds from small vessels;
for notwithstanding those  of larger size
may cease to bleed while under its influ-
ence, they will be apt to pour out blood
again, as soon as reaction and warmth are
developed in  the  part.  The long-conti-
nued use of cold  may besides prove pre-
judicial, by establishing a general chill in
the  enfeebled state of the  system, and
thus favour the development of dangerous
local determinations to the internal organs.
   Styptics are more  efficacious.  Those
chiefly  employed  are,  some one  of the
mineral or vegetable astringents, and va-
rious stimulating applications.  The sul-
phates of alumen, zinc, copper, and iron;
the acetates of zinc, lead, and copper; the
muriates  of  iron,  mercury, &c,  may  be
employed either  in solution or  powder.
Dosils of fine lint  imbued  in these mate-
rials should be introduced into the wound,
and  confined by a  compress.  Alcohol, tur-
pentine, diluted muriatic, nitric, sulphuric,
pyroligneous, or  acetic acids, may  be
used in the  same manner.   But perhaps
the  most effectual agent of this  kind  is
creosote.  An Italian  nostrum,  very an-
alogous  in its general characters to the
article just mentioned, and known under
the appellation of Aqua Binelli, has been
also much extolled as a hemostatic reme-
dy ;  but  the experiments  of  Dr. Davy
(American Journ. Med. Sc. XIII. 252.)
and  of Professor  Graefe  (Journal fur
Chirurgie und Angenheilkunde. XX. 47.;
and  American Journ. Med. Sc. XII. 53.)
have not confirmed these representations.
(See Creosote.)
   While it  cannot be  denied that these
styptic  applications possess the faculty of
arresting the flow of blood from small ar-
teries, they should not be  employed, ex-
cept as an indispensable alternative. They
always tend  to irritate and inflame the
wound, and may be thus  productive of
great mischief.   Cases may nevertheless
occur in which it  may be necessary to re-
sort to them, even at the hazard of their
bad  consequences.  They may be demand-
ed in wounds implicating a number of
vessels too small to be secured by liga-
 ture, and so situated that the hemorrhage
cannot be  commanded by pressure  or
other means.  After  some operations,
 moreover, when  a number of small ves- 
440
ARTERIES.  (Wounds—their Treatment.)
sels continue to pour out blood, they may
be resorted to when milder remedies fail
to check the bleeding.
  Absorbent   or  spongy substances,  as
finely scraped lint, sponge, &c, may some-
times be employed with  advantage for
the  purpose  of  arresting hemorrhage.
Their agency is chiefly mechanical.  The
blood becomes entangled in their spongy
or filamentous arrangement, where it im-
mediately coagulates, and  being retained
by the  structure of the  obstructing sub-
stance, it arrests the bleeding.  A popular
remedy of this kind is the web of the spi-
der.  The ancient surgeons employed pel-
lets  of chewed paper.   We  have  found
nothing  succeed  so well as scraped lea-
ther.   The most popular of all the  reme-
dies of this class is, the agaric.  It was
regarded by the older  surgeons as  a spe-
cific;  it however  possesses no  peculiar
virtues as a hemostatic agent.   Neverthe-
less  it may be sometimes  employed with
advantage.   When any  one of the sub-
stances mentioned is resorted to, it should
be placed as accurately upon the orifice
of the injured artery as possible, and so
arranged as  to fill up the wound  of the
soft parts oyer the vessel, when it presents
any  depth.   Slight pressure should then
be applied by means ofa bandage or other
means.
   Compression made  in the wound, and
directly over the opening of the vessel, is
a far more  effectual means of arresting
hemorrhage.   Should  the  wound of the
integument be of sufficient extent it may
sometimes be expedient for the surgeon
or an assistant to thrust the  finger or
thumb down to the bottom of it, in order
to make pressure  directly upon the ori-
fice of the vessel while preparations are
making to apply a ligature; and in some
cases, the divided artery may be grasped
between the thumb and finger, and held
until it is properly secured.  Should it be
determined to rely upon direct pressure,
soft lint, sponge, agaric, or some one of
the  substances mentioned above,  should
be thrust into the wound, and a graduated
compress adjusted  over  it, to be secured
by a bandage.  In  some cases, when the
external wound is very narrow, it may be
necessary to dilate  it inasmuch as the in-
tervention of a thick mass  of soft parts be-
tween the compress and the wounded ar-
tery, often so  far enfeebles the force em-
ployed, as to render it inadequate to pro-
duce the desired effect.  But should the
artery run over the surface of a bone fur-
nishing  a solid point  of resistance, this
precaution will not be necessary, as the
pressure under such  circumstances may
be rendered  effectual, even though the
compress  is not placed in direct contact
with the bottom of the wound.   Thus, in
wounds of the palmar arch, where, in con-
sequence  of the dense aponeurosis of the
hand, it is difficult to secure  the vessel by
a ligature, we have succeeded with great
ease in commanding  the hemorrhage, by
placing a  solid ball of some  substance in
the palm,  and binding the hand and fingers
firmly over it by several turns of a  roller
bandage.  Besides the compress which  is
applied directly to the wound, it will some-
times  be  useful  to apply another,  of an
elongated figure,  upon the course of the
vessel above,  in order to  interrupt the
passage of the blood.
  As the  presence of the compress in the
wound proves a source of great irritation,
while the constriction of the bandage cre-
ates great swelling and pain, this practice
should never be adopted, except when the
artery cannot  be  secured in a  ligature;
and if resorted to, it will be better to sub-
stitute  an artery press, where one is at
hand, or some one of  the expedients men-
tioned above, for the roller or spicabandage.
  The closure, and  subsequent  oblitera-
tion of the wounded artery, may be ef-
fected either by torsion, the plug, ligature,
or the actual cautery.
   Torsion is chiefly applicable to arteries
of small size, and cannot be conveniently
practised  at the bottom of a deep wound.
The  end  of the  vessel should be seized
and drawn out with  one  pair of forceps,
and then grasped transversely between
the  blades of another  pair, a few lines
higher up.  Seven or eight turns should
then be made with the forceps on the end,
so as to lacerate freely the inner tunics of
the artery, and twist its cellular coat The
advantages of this method of arresting he-
morrhage, and the rules for practising it,
will be more fully described in the article
 Torsion.
   The plug is seldom employed.  There
are  cases, however,  in which it is indis-
pensably  necessary.  The  nutritious ar-
tery of the tibia, which is divided in am-
putation,  occasionally pours out blood so
freely as  to render it necessary to plug itn
orifice.   This  may be done either with
wax, or a small piece of soft wood  as re-
commended by Dr. Physick.  The mid-
dle  meningeal artery is occasionally con-
tained within a complete canal in the sub-
stance of the parietal bone, or the groove
in that bone in which  it is lodged is deeper
than natural.  Should it be wounded un-
der  such  circumstances in  the operation 
ARTERIES.  (Wounds—their Treatment.)                441
of trephining, the hemorrhage  might be
arrested with a plug.  In other  cases, the
bleeding may be controlled by pressure
made from within  outward against the
bone, by a small stem or plate  of metal,
bent near its end at a right angle. When
an artery of large size, and very much os-
sified, is wounded, a conical plug of buck-
skin may be introduced into its orifice, and
confined by a properly adjusted  compress.
Under these circumstances,  the fragility
of the coats of the vessel is so great, that
the direct ligature will cut through them,
and when then the orifice can be readily
reached, the plug may be advantageously
substituted for the indirect ligature, as the
buckskin of which it  is composed, being
an animal substance, will be absorbed, and
will not occasion any permanent irrita-
tion. Rolls of bougie plaster have been suc-
cessfully employed for the same purpose,
by Chastanet ; but this material is much
more objectionable than the buckskin.
  The ligature  should be decidedly pre-
ferred to any of these  means, in all cases
admitting of its application.   The general
doctrines pertaining to this subject will
be discussed in the article Ligature, and
we shall only speak here of the rules to
be observed in applying it to the injuries
under consideration.   In  all cases where
the surgeon is called upon to treat wounds
of arteries which are  of sufficient size to
pour out much blood, he should first direct
his attention  to the possibility of tieing
the vessel.  If  the  bleeding has ceased
spontaneously, the wound should not be
disturbed; but if the hemorrhage still con-
tinues, the artery should be sought and
secured by a ligature.   The  blood should
be sponged away, and the  bleeding end
of the  artery drawn out  either with the
forceps or tenaculum.  Should the wound
of the  soft parts be deep,  as it will imme-
diately fill with blood, and obscure the
orifice  of the vessel, it will sometimes be
useful to compress the artery above, either
by the hand or the tourniquet in order to
discover the situation of the vessel by ob-
serving the point from which the jet pro-
ceeds when the pressure  is removed.  It
may then be seized, drawn out and se-
cured in a ligature.   In  some  instances,
owing to the narrowness  of the external
wound, this cannot be  done.  Under such
circumstances, an incision of the requisite
extent must be made along the course of
the artery, in order to admit of its being
reached and secured.  This  rule is of tlie
utmost importance,  inasmuch as more in-
jury is often inflicted by fruitless attempts
to secure an  artery in a narrow wound,
than would accrue from extensive inci-
sions.  Should the artery be very deep-
seated, it will often be difficult to draw it
out sufficiently by means of the tenacu-
lum  or artery forceps to admit  of the ap-
plication of a ligature.   Under such cir-
cumstances, the curved forceps and nee-
dle devised by Dr. Physick  for securing
deep-seated arteries  may be  employed
with advantage, or the same end may be
obtained by some one of the numerous in-
struments which  have been  invented  for
that purpose.  The vessel should be suffi-
ciently isolated from the  surrounding tis-
sues to admit of the ligature being applied
to it without including them in the  noose.
Cases may occur, however,  where, from
the great depth of the vessel, or the na-
ture  of its  relations, it   cannot  be suffi-
ciently separated to  receive  the  ligature
directly on its tunics.   Under such cir-
cumstances, it may become necessary to
pass a curved needle, armed with a liga-
ture, around it, including within its  sweep
a mass of the tissues surrounding the ar-
tery, which must be comprised with it in
the knot   This  is what is denominated
the mediate or indirect ligature. It should
never be employed except as a matter of
absolute necessity, inasmuch  as it is apt,
in consequence of the veins, nerves, &c,
being included, to excite  great pain and
inflammation; and it may lead  to even
more formidable  consequences.  Another
condition demanding the  mediate ligature
is, extreme ossification or degeneration of
the coats of the artery,   rendering them
too brittle  to sustain the constriction of
the thread, without the  intervention  of
some other substance.
   Sometimes  the lower as well as the up-
per end of the  artery pours  out  blood.
When this is the case, both should be tied
in the same manner.  Indeed, it will be
proper to observe this rule, even though
there should be no bleeding from the lower
end  at the time, since it very generally
happens  after the lapse of some  time, in
consequence of the freedom of the anas-
tomosing vessels, that the blood  passes
round into the lower end of the artery,
and  gives  rise to reflux  bleeding.   This
precaution will be doubly necessary when
an artery has  been wounded in the  imme-
diate vicinity of numerous  anastomosing
vessels;  as, for example, near the wrist,
the bend of the  arm, the ankle, or the
knee. Indeed, in  all cases when the lower
end  of the artery can be found without
making extensive incisions,  or inflicting
other serious  injury of the soft  parts,  it
will be  advisable to secure it as  a pre- 
442                 ARTERIES. (Wounds—their Treatment.)
cautionary measure against subsequent he-
morrhage.   The adoption of this rule of
practice would often save much pain and
trouble, and sometimes obviate very seri-
ous consequences.   As  the  ends of the
wounded  artery cannot retract when the
vessel is not entirely severed, in all cases
of that  kind the artery  should be cut en-
tirely across, whether compression,  liga-
ture, or any other means of arresting he-
morrhage be resorted to.
   Silk  or animal ligatures may be  em-
ployed at the option  of the surgeon.  The
latter, however, cannot always be confided
in for vessels of large size, as they are apt
to become soft and decomposed, before the
accomplishment of the adhesive process by
which the calibre of the vessel is oblite-
rated.  They succeed very well with arte-
ries of medium  size;  and when a vessel
has been wounded pertaining to some pro-
truding organ, which requires to be return-
ed into a natural cavity, they should always
be preferred, as the ends can be cut close to
the knot, and the noose itself will soon be
absorbed.  When a silk ligature is em-
ployed, one end should be cut close to the
knot, and the other brought out at the
external opening. (See  Ligature.)  The
wound  should then be  sponged free of
blood, wiped dry, and have its edges neatly
approximated by adhesive  strips, or su-
tures,  according to circumstances.  (See
Wounds.)
   Cases sometimes  occur in  which it  is
impossible, or difficult to secure the ves-
sel in the wound. The deep-seated palmar
arch, and the plantar arteries, owing  to
the  resistant aponeurosis which covers
them, are exceedingly difficult to secure
when wounded.   They  project the  blood
in the midst of the surrounding parts  to
such a degree,  that when that fluid be-
comes coagulated, interlaced as it is with
firm  aponeurotic bands, it will  often be
impossible to find the wounded vessel  in
the midst of the confused mass which  is
thus formed.  In such cases, therefore,  if
the hemorrhage  cannot  be restrained by
pressure,  it will be necessary to secure
the main artery  above the seat of injury.
If the tarsal artery be wounded,  the pos-
terior tibial should be tied behind the in-
ternal malleolus, and if  the bleeding con-
tinue, pressure  must be  made on the dor-
sal artery of the  foot,  in the  manner al-
ready directed.   When  the palmar arch
is wounded, it may be necessary to secure
either the radial or ulnar artery,  accord-
ing as the injury is more  immediately con-
nected with the  one or  the other.  The
one that  is not  tied, must be compressed
near the wrist.   When a wound is in-
flicted on the posterior tibial or the fibular
artery in the fleshy part of the leg, or on
the anterior tibial where it perforates the
interosseous ligament,  it will  be 60  diffi-
cult to apply a ligature to the part of the
vessel injured, that it will in general be
better  to secure  the femoral artery high
up in the thigh.   Wounds implicating the
internal maxillary artery will require the
ligature to be applied either to the com-
mon, or external carotid; and it may be-
come necessary in wounds of the tongue,
to tie the lingual artery; or in injuries of
the thyroid gland, to  secure the artery
leading to that body near its origin.
  Cautery is another means of arresting
hemorrhage which must be sometimes re-
sorted to.  It was the chief reliance of the
ancient surgeons, and although not so
much employed since the discovery of the
ligature, it is often  a valuable  resource
when all other means fail.   It will be es-
pecially demanded in  wounds about the
mouth, tongue, tonsils, antrum, anus, &c,
as in many cases of that kind, the ligature
is not available.   A cautery button of pro-
per shape should be brought to white heat,
and applied quickly to the bleeding ves-
sels, the blood being previously sponged
from tlie  wound.  It is exceedingly im-
portant to have the iron heated  to a very
high temperature, because in that condi-
tion,  it  immediately  kills the  parts to
which  it is applied, and  is consequently
less painful than when the temperature is
less.  Under  the latter circumstances, it
irritates and inflames the structures with-
out destroying their vitality, and in this
way, although it may stop the bleeding
for  the time, it is apt to occasion second-
ary hemorrhage.  (See  Cautery.)
  We do not propose to treat in this place
of the various causes of secondary hemor-
rhage, or to indicate the proper treatment
to be pursued under all the circumstances
giving rise to it.  Information upon these
points will be found in the articles Aneu-
rism, Ligature,  and Wounds.  When he-
morrhage has been arrested for some time
by compression,  ligature, cautery, or any
one of the means indicated, and recurs af-
ter considerable  inflammation  and change
of texture  has taken place in the wound,
it will seldom be practicable  to tie the
vessel at the original seat of injury.  Any
efforts  to  do so  will be attended with ex-
treme  suffering,  and the artery will, be-
sides, be  so agglutinated with  the sur-
rounding parts,  as to render it impossible
to isolate it  sufficiently to apply a liga-
ture.  Even if this could be done, its tunica 
ARTERIES.  (Nervous Affections.)                     443
will generally be found so softened by dis-
ease, that they will be cut through by the
thread as soon as the knot is drawn.   Un-
der these circumstances,  if the bleeding
cannot  be  commanded by compression,
cautery, or  some other means, it will be
necessary to expose  the  artery at a pro-
per point above  or below the wound, ac-
cording as the hemorrhage proceeds from
the upper or lower end, and secure it by
ligature.  This procedure will often be-
come necessary after contused  wounds of
arteries.  It not unfrequently happens in
injuries of this kind, that the coats of the
vessel are so much bruised, that at the ex-
piration of several days they slough away,
and  give rise to profuse hemorrhage.  In
all such  cases,  therefore,  the  surgeon
should enjoin positive quietude, and have
a tourniquet buckled loosely on the limb,
with instructions to turn the screw in the
event of any bleeding taking place.  Should
hemorrhage ensue, the artery must be ex-
posed  and secured by ligature above the
wound.

  Bibliography.—Besides the systems of Sur-
gery, the following authors may be consulted on
the subject of wounded arteries:
  Petit, (J. L.)   Mimoire  sur la maniere d'ar-
riter les himorragies.  Mem. de l'Acad. Royale
iles Sc.  1731. p. 85. 1732. p. 388.   1735.  p. 435.
  Morand. Observations sur les cliangemens qui
arrivent aux  arteres coupies, ou  Von fait  voir
au'ils contribuent essenliellement a la cessation de
Vhimorrhage.  Mem. de l'Acad. des  Sc  1736. p.
321.
  Morand. Sur un moyen d'arriter le sangdes
arteres, sans le secours de la ligature.  Acad. Roy.
de Chirurgie.   1753.  II. 220.
  Pouteau.  Sur les moyens  que la nature em-
ploiepour arriter les himorrhagies, et pour aider
i'effet des ligatures, &c.  Melanges de Chirurgie.
Lyons, 1760.
  Kirkland.  Essay on the method of suppress-
ing hemorrhage from divided arteries.  London,
1763.
  Le Compte. Risultats de quelques expiriences
Venules  sur plusieurs animaux, pour faire Vessai
de la nouveUe  mithode de trailer les plaies des ar-
teres.  Hist de la Soc. Roy. de Med. 1776. 305.
  Callisen. Diss, de vulneribus arteriarum. Co-
penh. 1787.
  Deschamps.  Observations  et reflexions sur la
ligature des principales arteres blessies-  Paris,
1797.
  Bell, (John.)  Discourses on the nature and
< ure of wounds.  2 vols.  Edinburgh, 1800.
  Jones.  A treatise on the process  employed by
nature in suppressing hemorrhage from divided
and punctured arteries, &c.  London, 1808.  Phi-
ladelphia, 1811.
  Beclard.  Recherches el expiriences sur les
Uessures des  arteres. Mem. de la Soc. Med. d'-
Emnlat VIH. 569. Paris.
  Ebrl. Dissert, de nalura medicatrice sicubi or-
teritB vulnerata et tigaturafuerint. 4to.  Giessen,
1826.
  Jameson, (Horatio.)  Observations upon trau-
matic hemorrhage, illustrated by experiments upon
living animals.  Medical Recorder. XI.  3. Phi-
lada. 1827.
  Guthrie.  On the diseases and injuries of ar-
teries, &c.  London, 1830.
  Smith, (Nathan.)  Remarks on the  sponta-
neous suppression of hemorrhage, &c.  Surgical
Memoirs.  Edited  by Nathan R. Smith, M. D.
p. 187.  Baltimore,  1831.
  Berard.  Art. Arteres, blessures des,  in Dic-
tionnaire de Medecine. 2d edit. IV. 72. Paris, 1833.
  Graefe, (C. F. Von.)   Bericht ueber das  CM-
nische Chirurgisch  inslitut. der Universilat. zu
Berlin, fur das Jahr  1832.  4to.  Berlin, 1833.
Also, Journal  fur Chirurgie  und AngenLc.l-
kunde.  XX. 1.  1833.
  Sanson.  Art Plaies.  Dictionnaire de Med.
et de Chirurg. Pratique. Tome XIII. Paris, 1835.
  Smith, (Nathan  R.)  Surgical anatomy of the
arteries.  2d edit. 4to. with plates.  Bait. lfeo.
  See also Bibliography of Aneurism, Wounds,
Ligature, Hemorrhage, and Torsion.

   "i  6.  Nervous affections of the arteries.
The numerous filaments  of nerves which
twine upon the surface of the arteries, and
form an  intricate  plexus  upon  some of
their principal divisions, render these ves-
sels susceptible of being influenced  by any
serious disturbance  taking place  in  the
nervous system,  especially in  its gangli-
onic portion.  But as the nervous affec-
tions of the heart are generally manifested
in the  arteries,  it  is impossible to discri-
minate in many cases, between the symp-
toms which appertain properly to the for-
mer, and those  which arise  from a dis-
eased condition of the latter.  Many of the
phenomena of disturbed innervation of the
arteries are, besides, common to inflam-
mation and  other  morbid conditions of
those vessels. Owing to these causes, and
the total absence of those collateral lights
which pathological  anatomy affords in the
investigation of other diseases, our know-
ledge of the nervous affections peculiar to
the  blood-vessels is  exceedingly meagre
and unsatisfactory.   As the most  impor-
tant facts pertaining to this subject have
been already detailed in the article Abdo-
minal pulsations (Vol. I.  p. 83.),  it will
not  be  necessary to enter into any exten-
sive disquisitions in this place.
   1. Neuralgia  of the  arteries.  Owing
to the  obscure  sensibility of the gangli-
onic nerves, from which the arteries de-
rive their chief supply, preternatural irri-
tation of these vessels is seldom attended
with much pain.   While, therefore, there
is reason to infer, that  they, in common
with other organs,  are liable to neuralgic
affections, this circumstance explains the
absence of that degree of pain an" c,,'r "■"-
ing, which characterizes this disease when
it seizes upon the sensitive  nerves.  It
rather  constitutes a state of organic nerv-
ous erethism, indicated by preternatural 
444

pulsation and  throbbing of the arteries,
which is either local or diffused, according
to the  extent of the pathological condi-
tion.   Laennec nevertheless affirms, that
these vessels are sometimes affected with
a  neuralgic  condition,  characterized  by
pain more or less acute, either continuous
or intermittent,  following  the  course of
the  arteries,  and  apparently having  its
seat in the ganglionic nerves with which
they are  supplied.   This pain, he repre-
sents,  is  in general  less acute than that
which is manifested by the cerebro-spinal
nerves, and it is more particularly apt to
occur in hypochondriacs and in hysterical
females, than in other individuals.  (Aus-
cultation Mediate.  II. 756.  Paris, 1826.)
It must be confessed, however, notwith-
standing this authority, that pain from this
cause  alone, following  the course of the
arteries,  is an exceedingly  rare  occur-
rence.
   2. Preternatural pulsation of the arte-
ries from nervous affection.  A high de-
gree of nervous erethism of the  arterial
tunics renders them  liable to be affected
with preternatural pulsations and throb-
bings,  under the influence of a variety of
causes, both physical and mental.  This
condition may exist throughout the whole
vascular system, disposing it to be thrown
into a general turmoil under the operation
of any unusual excitement, or it  may be
confined to a  particular set of arteries.
Violent pulsations  are often  experienced
within the abdomen and thorax, in conse-
quence  of the  aorta  and  its principal
branches being involved in this neuropa-
thic condition,  and  in  some cases,  the
sympathetic disturbance proceeding from
this source is so great,  as to threaten se-
rious consequences. In delicate hysterical
females, hypochondriacs, and dyspeptics,
we have  sometimes  seen the abdominal
pulsations so violent, as  to be a source  of
serious distress and alarm to the patient;
and occasionally they seem to be not con-
fined to the abdominal aorta, but are dif-
fused along the branches of the  cceliac,
the mesenteric, and  other arteries distri-
buted  to  the  abdominal  organs.  When
the thoracic portion of the aorta is affect-
ed, there is  frequently, besides the dis-
tressing pulsation  and  throbbing of the
vessel,  violent palpitation  of the  heart,
difficult respiration, and a disposition  to
syncope from the slightest cause.  These
thoracic and abdominal pulsations  are in-
deed often so energetic, that they are lia-
ble to  be mistaken for aneurism of the
aorta—a mistake which  is still more apt
to be made, because  of this condition of
ARTERIES.  (Nervous Affections.)
the arteries being sometimes attended with
the bruit de soujflet, and the purring tre-
mor common to aneurism.  Numerous ex-
amples of a false  diagnosis under these
circumstances might  be  cited, in which,
after death, notwithstanding the strong in-
dications of aneurism of the aorta which
had preceded,  dissection  revealed no ap-
preciable lesion of that vessel.  The caro-
tid and other arteries are  not unfrequently
affected  in a similar manner, and in feeble
delicate  females of a nervous tempera-
ment, who are affected with preternatural
erethism of the brain, it is  not uncommon
to see the carotids and all the arteries of
the  head pulsating so violently, as to be-
come a source of great distress.  Such in-
dividuals are  indeed  sometimes  affected
with a general perturbation of the whole
arterial system under  every source of ex-
citement, either mental or  corporeal, and
in some  such we have seen this condition
so strongly developed, that they have com-
plained that the throbbing was distressing
even at the fingers' ends.   A similar con-
dition is very frequently  observed  during
convalescence from protracted fevers, in
individuals affected with anemia or other
perverted conditions  of the  circulating
fluids, and after excessive losses of blooa
In such  cases,  there is violent throbbing
of the arteries, and the heart is affected
with distressing palpitations, often giving
rise to great sympathetic disturbance of
the respiratory function.  The pulse has
a peculiar full, vibratory,  shattered thrill,
and a  great sense  of exhaustion or a dis-
position   to  syncope  is  experienced  on
taking even slight exercise, or under the
influence of any mental emotion.  This
condition of the  circulation, when it has
been observed after protracted fevers, has
been by some  attributed to an inflamed
state of the lining membrane  of the arte-
ries.  We are satisfied, from the result ot
a close attention to the subject, ancrthe
effect  of remedies, that  it  is  owing, in a
majority of cases at least, to  a simple state
of nervous erethism of the vascular sys-
tem, together with a deteriorated state of
the blood, which renders it more irritating
to the  coats of the vessels than in health.
  Besides the preternatural  excitement
and  pulsation to which  the arteries are
liable, when affected with  the high degree
of nervous erethism under  consideration,
Laennec has  affirmed, that  they some-
times take on a kind of spasmodic action,
which is characterized by  the bruit de
soufflet, and the purring tremor.   He re-
presents  that the only pathological condi-
tion  which is constantly  associated with 
ARTERIES.  (Nervous Affections.)                    445
the first of these physical signs, as mani-
fested by the heart and arteries is, a nerv-
ous agitation more or less marked, which
is in relation with the extent of the sound,
or in other words, with the number and
volume of the arteries in which it is ob-
served. The bruit de souffiet is never per-
ceived in the arteries of an individual af-
fected with  open febrile excitement,  ex-
cept the subject possess great nervous mo-
bility.   He remarks  that when this  sign
is perceived in the aorta, the carotids, and
the arterial trunks of the  extremities, si-
multaneously, the patient is in  an extreme
state  of anguish  and anxiety, and if the
heart, together with the greater part of
the prtcrial system, present this condition,
his life is in peril.  When, on the other
hand, only one or two arteries are affected,
as, for example, the subclavian and caro-
tid, the state  of the functions does not al-
ways announce a positive condition of dis-
ease.   The bruit de souffiet is very com-
mon in a slight degree in  hypochondriacs
and hysterical females, and in  such  indi-
viduals is particularly manifest in the ca-
rotids, the subclavian, and sometimes in
the abdominal aorta.  He has,  besides, re-
marked the same thing in young and irri-
table subjects who are greatly disposed to
hemorrhage of various kinds; but subjoins,
that it is  exceedingly rare in individuals
affected with open and violent inflamma-
tion.  In  a  single case he  observed it
throughout the whole extent  of the aorta
ofa delicate and irritable child affected
with croup,  in which it  continued two
years after  convalescenee.   That  it is
purely of a nervous character, and  the re-
sult of spasm, he infers from the fact, that
most of the individuals of the tempera-
ment mentioned who are liable to  it,  sel-
dom present it except in one or two arte-
ries, and in them only at intervals.  When
they are  perfectly tranquil,   the  stetho-
scope applied to the carotid, or the  subcla-
vian, does not reveal  any other sound than
that which is natural to the arteries; but
the slightest disturbance—walking in  a
quick pace,  coughing, a forcible inspira-
tion, an emotion  of pleasure or pain, im-
mediately change the character of  the ar-
terial impulse, and in an  instant, convert
it into the bruit  de souffiet, which some-
times becomes sibilant, but disappears as
soon as tranquillity is restored. It may be
again induced, however, by compressing
the artery slightly with the finger above
or below the point to  which  the  instru-
ment is applied, especially if the finger be
elevated and depressed alternately.   (Op.
Cit. II.  442.)
  vol. ii.          38
  These statements are highly interest-
ing, but they are not sufficient to justify
fully the  inference  which  has been  de-
duced  from them.   We are perfectly sa-
tisfied, that a state of nervous agitation
affecting the heart and arteries is capable
of developing  both  the bruit de souffiet
and the fremissement cataire; yet there
is no positive  evidence that these pheno-
mena are a consequence of a spasmodic
action  of the vessels.   They may, on the
contrary,  be  induced  by  various  other
causes, under  particular states  of  the cir-
culation.  We have in  several instances
discovered bruit de souffiet in the  arteries
of individuals  affected with  anemia, when
the blood was  preternaturally watery, and
the action of the heart and arteries turbu-
lent and irregular,  as  it frequently is in
that disease.  We  are inclined to think,
that a watery state  of the blood,  coexist-
ing with preternatural acceleration of the
circulation,  will very often give rise  to
the sound in question;  and from the phe-
nomena observed in some cases, we have
suspected that the bruit de souffiet may be
frequently produced by the forcible pro-
jection of the thin  watery blood against
the angular prominences which are form-
ed by the bifurcation of the arteries.   If,
therefore, it may be  sometimes  an evi-
dence of spasm of the vessels, as supposed
by Laennec, it may also owe its existence
to other causes, and should not be regard-
ed as conclusive evidence of the presence
of that condition.
  The causes capable  of giving rise to a
state of preternatural nervous erethism of
the arteries are so  numerous,  that  they
cannot be designated. It has been already
remarked, that this  state often exists dur-
ing convalescence from protracted fevers.
We have repeatedly seen  it  induced  by
the imprudent use  of mercury;  and ex-
cessive losses of blood, either by the abuse
of venesection, or hemorrhage, almost con-
stantly give rise to disturbed innervation
in the circulatory system. Anemia, taking
place as a consequence of impaired hema-
tosis;  obscure and protracted irritation of
the ganglionic nerves,  as  in dyspepsia;
preternatural  irritation of the  spinal mar-
row,  and an  excitable nervous tempera-
ment, with  a proclivity to hysteria or hy-
pochondriasis, may also be enumerated as
causes.  It may likewise be  induced  by
the imprudent use of opium, tobacco, and
other narcotics.
   Treatment.  When the impulse of the
arteries  is much increased, Laennec re-
commends frequent small abstractions  of
blood.  This practice, however, can seldom 
446                           ARTER.—ARTIS.
be necessary, except when the morbid ere-
thism of the arteries is associated with
hypertrophy of the heart; and  if gene-
rally followed, it would prove highly mis-
chievous.   The majority of cases which
have  fallen under our observation, have
exacted an opposite course.   The vege-
table and mineral tonics, cool ablutions, or
sprinkling  the  body from  time  to time
with  cool  water, and, when  admissible,
the shower-bath, we have generally found
to be the most effectual remedies.  Of all
the mineral tonics, iron is entitled to most
confidence; but zinc, copper, bismuth, ar-
senic, &c, may be employed with advan-
tage.   When there is naturally great mo-
bility of the nervous system,  it must  be
soothed by  means of sedatives and anti-
spasmodics.  Amongst the first  class  of
remedies,  prussic acid, acetate  of lead,
laurel-water, morphia, stramonium, lactu-
carium, belladonna, camphor, &c, may be
selected;  and  in feeble hystericky fe-
males, musk, castor, assafetida, &c,  may
be occasionally employed with advantage.
Proper attention should always be paid to
the first passages, and  such means em-
ployed as to maintain the healthy play of
the secretory organs, and secure regular
alvine discharges. When practicable, ex-
ercise in the open air, change of scene,
and recreation of the mind, will be the
most valuable remedies, and should not be
neglected.   Should there be indications
of neuralgia, it must be treated according
to the principles laid down in the article
appropriated to that subject.  In some  in-
stances, galvanism will be found useful,
by restoring the  equilibrium between the
functional  acts of the organs.
   ) 7. Entozoa of the arteries.   No ex-
ample, as  far as we are  acquainted, has
been reported  of an entozoa of any kind
having been discovered either within the
arteries of the human  subject, or in the
substance  of the tunics of those vessels.
It is well known to veterinary surgeons,
however,  that the arteries of the horse,
ass, dog, and some other animals, are  re-
markably  liable  to be  infested  by these
 parasites.   Ruysch long since discovered
 a bundle  of oblong worms,  clustered to-
 gether in the aorta of a horse; and other
 examples were subsequently described by
 Morgagni, Schulz, and others,  in which
 similar animals were found  in the  aorta
 and mesenteric artery.  In  more recent
 times, these entozoa of the arteries have
 been more particularly noticed by Donald
 Monro, Rudolphi, Grognier, Hodgson,
 Chabert,  Bremser, Girard, Trousseau
 and Leblanc, and others.  They are par-
ticularly  apt  to take up  their habitation
within aneurismal tumours affecting the
arteries- of these  animals; but we have
also frequently found them forming large
packets in the cavities of the heart, espe-
cially of  the dog.   Those which are most
commonly enumerated are ihe Strongylus
Armatus, and Strongylus trigonocepha-
lus. Rudolphi.         r  GEDmm8

  ARTERIOTOMY.  (From a^ca, an
artery, and tsfivnv, to cut.)   Ae-tqeuvtopta,
Gr.;  Arteriotomia,  Lat;   Arteriotomie,
Fr.  The opening of an artery for the pur-
pose of blood-letting. (See Blood-letting.)
It has  also been sometimes used to desig-
nate that part of anatomy which treats of
the dissection of arteries.        I. H.
  ARTHRALGIA,  or  ARTHRONAL-
GIA.  (From a^O^ov, a joint, and afcyoj,
pain.)  Pain in the joints.       I. H.
  ARTHRITIC.   (From ag0gw, a joint.)
Relating to gout,  gouty.         I. H.
  ARTHRITIS.  (Same derivation.)   In-
flammation of the joints.  (See Joints, in-
flammation of; Gout, and  Rheumatism.
                               I. H.
  ARTHROCACE. (From a^ov, a joint,
and xaxoj, bad.)   This is  a generic term,
for all diseases of the joints; but it is
sometimes restricted to express caries of
these parts.                    I. H.
  ARTHRODIA.  That species of Arti-
culation  which is formed by the head of a
bone  applied to a shallow socket and al-
lowing of motion in various directions.
                                I.H.
   ARTHRODYNIA.   (From o^eeyv, a
joint, and oSwr, pain.)  Pain in the joints.
It is  more especially applied to slight ar-
ticular pains, unattended with heat or tu-
mefaction.                      I. H.
   ARTHROPUOSIS.   (From «<«?*, a
joint, and rtvov,  pus.)  Suppuration of the
joints. Cullen gave this epithet to a class
of diseases, which he described as charac-
terized by deep, obtuse, durable pains of
the joints  or muscles, little or no tume-
faction, no inflammation, with hectic fever
and suppuration of the part.  He conceived
that in gout and rheumatism, suppuration
never occurred, and therefore  that those
diseases were  generically  distinct  from
the  affection he  wished to designate by
the above term. (See Joints, suppuration
of;  Gout, and Rheumatism.     I. H.
   ARTICHOKE.  (See  Cinaria.)
   ARTICULAR.  Appertaining  to the
joints.                          I. H.
   ARTICULATION.  (See Joints.)
   ARTISANS, Diseases of.  (See Occu-
pations,  their influence on health.) 
ARUM.—ASARUM.
447
  ARUM.   (Botany and Mat. Med.)
  Sex. Syst. Monoecia Polyandria.  Nat.
 Ord.  Aroideae.
  Gen. Ch.  Spathe one-leaved, cucullate,
 convolute at base.   Spadix naked at the
 extremity, with sessile anthers in the mid-
 dle, and ovaries at base.  Berry one-cell-
 ed, many-seeded.  Beck.
  Most,  if not all the species of this ge-
 nus, are endowed with highly acrid and
 caustic  properties,  dependent on a  very
 volatile principle, destructible by heat or
 even the action of the air;  it has never
 been obtained in a separate form, nor is it
 capable of combining with water, alcohol,
 ether, or the oils.  The officinal species
 are  A. maculatum, D.;  A. triphyllum,
 U.S.
   A. maculatum. Wake Robin.   Cuckoo
 Pint  Pied de veau,  Fr.;  Aronswurzel,
 Germ.
   Sp> Ch.  Leaves radical,  hastate sagit-
 tate ; lobes deflexed; spadix club-shaped,
 obtuse, shorter than the spathe.  Hooker.
   This species is found in most parts of
 Europe.  The root  is  solid, tuberous, and
 rounded. When fresh,  it contains a milky
 juice of extreme acrimony, which  when
 applied to the tongue, or to any part of the
 body  denuded  of the  cuticle,  causes a
 burning heat, which lasts for some hours.
 When dried, it becomes perfectly inert,
 and affords an abundant fecula which may
 be used as a succedaneum for wheat flour,
 and  is sold for that purpose in some parts
 of England.  The  volatile  principle on
 which the  acrimony of the  root depends
 cannot be obtained on  distdlation, nor is it
 contained in the extract, though at the
 same time these processes deprive  the
 root of all active properties.   The root, in
 a partially dried state,  has been given in
 dyspepsia and in some  rheumatic cases, in
 doses of ten or fifteen grains, three or four
 times a day.  The celebrated French cos-
 metic, Poudre  de Cypres, is merely the
 fecula of this root mixed with  some aro-
 matics.
  A. triphyllum.   Indian turnip.    Dra-
 gon root
  Sp. Ch. Stemless; leaves ternate; leaf-
 lets ovate, acuminate, very entire;  spadix
 clavate;  spathe ped uncled, ovate, acumi-
 nate, convolute  below, flat and bent  over
 above. Beck.
  The Indian turnip  is  a native of the
 United States.  It occurs in rich shady
 woods, or in damp situations,  flowering
from  May  to July, and  presenting its
bright scarlet berries during the summer
and autumn.  It has a perennial,  round,
somewhat flattened, tuberous root, covered
with a dark, loosely  attached epidermis.
The leaves are from  one to two in num-
ber,  supported on long sheathing petioles,
and composed of three oval or oblong acu-
minate leaflets.  The  spathe is cylindrical
at base,  but  expanded and bent  over at
top; of either a green or purple colour, or
of both in alternate stripes.  The spadix
is cylindrical, bearing the flowers at the
base.
   The whole plant and more especially
the root  is acrid, and even caustic to the
tongue, but scarcely  excites rubefaction
of the skin.  The root has obtained some
celebrity in domestic practice as a remedy
in some forms of dyspepsia, and more par-
ticularly  where there  is flatulence: it has
also been used in rheumatic affections and
even in chronic inflammations of the re-
spiratory organs, in which, however, it is
more liable to be productive of evil results
than to effect a cure, as it is an active
stimulant rapidly increasing the force of
the circulation.  The fresh roots are too
caustic to be administered, and must be
kept  until they have lost some  of their
acrimony by the volatilization of the acrid
principle. The usual mode of giving this
remedy is in powder, with milk, or made
into a conserve.  The dried roots yield
one-fourth of their weight of a pure fecula,
closely resembling arrow-root and form-
ing a good substitute for this article. Boil-
ing also deprives them of any deleterious
properties, and renders them esculent
                      R. E. Griffith.
   ARYTENOID.  (From acvttutu, a fun-
nel, and 11805, form.)   Funnel-shaped.
   Arytenoid cartilages.   Two cartilages
of the larynx.  (See Voice, organs of J)
   Arytenoid glands.   Small glands situ-
ated anteriorly to the arytenoid cartilages,
and which pour out a mucous fluid to lu-
bricate the larynx.
   Arytenoid muscle.   A small  muscle
which passes from  one arytenoid muscle
to the other.  (See Voice, organs of,  and
Muscles.)                       I. H.
   ASARABACCA.   (See Asarum.)
   ASARUM.  (Botany and Mat. Med.)
   Sex. Syst.   Dodecandria  Monogynia.
Nat. Ord.  Aristolochiae.
  Gen. Ch.  Calyx three or four-cleft, sit-
ting on the germ.  Corolla none.  Cap-
sule coriaceous, crowned. Willd.
   1. A. Canadense.—Canada snake-root.
Wild ginger.—Sp. Ch.  "Leaves broad
reniform, paired;  calyx woolly,  deeply
three-parted; segments sublanceolate, re-
flected."  Pursh.  This species of Asarum
has a perennial, long,  creeping, somewhat
jointed, fleshy, yellowish root with radicles 
448
ASARUM.
of a similar colour.  The  stem is very
short, dividing, before it  rises above the
ground,  into two long, hairy footstalks,
each of which supports a broad kidney-
shaped leaf, pubescent upon both surfaces.
A solitary flower stands in the fork of the
stem, upon a hairy pendulous peduncle,
and is often concealed under the loose soil
or decaying vegetable matter, so that the
two leaves with their petioles are the only
parts which appear above  the ground.
The calyx  is very hairy or woolly, and is
divided into three broad, concave, acumi-
nate segments, with the ends reflexed, of
a  deep  brownish-purple colour on the in-
side, and of a dull purple, inclining  to
greenish, externally. The filaments, which
are twelve in number, stand upon the
germ, and rise with a slender point above
the anthers attached to them.   Near the
divisions of the calyx are three filament-
ous bodies which may be considered  as
nectaries.   The pistil consists of a some-
what hexagonal  germ,  and a  conical
grooved style ksurmounted by six revolute
stigmas.  The plant is  indigenous, grow-
ing in woods and  shady places, from Ca-
nada to Carolina.  Its period of flowering
is from  April to July. All parts of it have
a grateful aromatic odour, which is most
powerful in the root.   This portion is re-
cognized among the secondary medicines
by our national Pharmacopoeia, under the
name of Asarum.
   The  dried root of the  Asarum Cana-
dense, " as we have  seen it  in the shops,
is in long, more or less contorted pieces,
of a thickness from that of a straw to that
of a goose-quill,  brownish and wrinkled
externally, whitish within, hard and brit-
tle, and frequently  furnished  with short
fibres.  Its taste is agreeably  aromatic and
slightly bitter, said to be intermediate be-
tween that of ginger and serpentaria, but,
in our  opinion, bearing a closer resem-
blance to that of cardamom.  The taste
of the petioles, which  usually accompany
the root, is more bitter, and less aromatic."
(U. S. Dispensatory.)  The root was im-
perfectly  analyzed by Dr. Bigelow, who
found it to contain a fragrant volatile oil,
a bitter  resin, starch,  and gummy matter.
It yields  its virtues to alcohol, and less
readily to water.
   It was naturally inferred from the close
resemblance of this species of Asarum to
the A. Europaum, that it possessed emetic
powers;  and such is stated to be the fact
by several authors whom  we  have con-
sulted.   Dr. Bigelow, however, observes,
that the  opinion was probably taken from
Cornutus, who, in his plants of Canada,
informs us, that two spoonsful of the juice
of the leaves of the Asarum are found to
evacuate  the stomach  powerfully.   But
this author referred rather to the European
than the American species; and Dr. Bige-
low is inclined to think, that  if such an
operation was really produced  by our na-
tive plant, it was ascribable to the pecu-
liar irritability of the patient's stomach,
which would have caused the same effect
to  result  from an equal amount of any
crude vegetable juice; as he has seen the
root employed in considerable quantities
without giving rise to vomiting or eveu
nausea.  (Amer. Med. Bot.  I. 152.)  The
root is an aromatic stimulant tonic, having
diaphoretic properties,  somewhat  analo-
gous  in its action to the Virginia snake-
root, and applicable to similar cases.  Dr.
Firth  employed  it  with success  in  the
tetanus of children arising from cold.   It
is said to be sometimes used by the coun-
try people as  a substitute for ginger,
whence it derived one of the  vernacular
names by which it is recognized. It may
be  given in powder or tincture. The dose
in substance is twenty or thirty grains.
  2. A. Europaum.—Asarabacca.—Asa-
ret, Cabaret, Fr.; Haselwurz, Germ.
  Sp. Ch.  " Leaves reniform, obtuse, bi-
nate." Linn. Sp.  Plant, ed. Willd.
  This species bears a very close resem-
blance to the preceding. It is a native of
Europe, growing in woods  and   shady
places,  and flowering in April and May.
All parts  of it are active.  The root and
leaves  are recognized  by  many of  the
continental Pharmacopoeias;  the  leaves
only by those of Great Britain.  It  is  not
ranked among the officinal medicines in
the United States.
  The  dried root is about as  thick as a
straw, quadrangular, knotted and twisted,
furnished with fibres on the under sur-
face, brittle, of a grayish colour sometimes
inclining  to brown externally, whitish or
light-brownish internally,  of a peculiar
not disagreeable odour somewhat like that
of pepper, and of an acrid aromatic taste,
which leaves for a time a benumbing im-
pression on  the  tongue.  The powder,
which  is  of  a  grayish colour, excites
sneezing  when  applied to the nostrils.
The leaves have little odour, and a taste
similar to that  of the  root  but  much
weaker, and at the  same  time bitterish.
They  afford a yellowish-green powder.
Both  parts are commonly thought to lose
their activity by keeping, and  ultimately
to become  inert;  but Geiger states that
this result need  not be apprehended, if
they are kept in  a  perfectly  dry  place. 
ASCITES.  (Symptoms.)
449
 Their virtues are extracted both by water
 and alcohol,  but are dissipated by  long
 boiling.   Vinegar  is said to render them
 inert   MM. Lassaigne  and  Feneulle
 found in the root  a concrete volatile oil,
 an acrid fixed oil, and a yellow nauseous
 emetic substance analogous to cytisin, be-
 sides other principles of less importance.
    Therapeutic  use.  The root of asara-
 bacca, either fresh or  carefully dried, is
 emetic and cathartic, and by some writers
 is said to be diuretic. According to Rich-
 ter, it  exercises  also  a stimulant influ-
 ence upon the nervous and vascular sys-
 tems. Snuffed up the nostrils in the state
 of powder, in the  quantity of one or two
 grains, it produces  much irritation attend-
 ed with sneezing and  a copious flow of
 mucus, which is said to continue some-
 times for several days.   The leaves have
 tlje same properties, but in an inferior de-
 gree.   Asarabacca  was  formerly much
 used as an emetic; but  in this respect has
 been almost entirely superseded by ipeca-
 cuanha.   It has been recommended in in-
 termittent fever,  menstrual irregularities,
 dropsies, &c.  At present, however,  it is
 little employed  except as an errhine, in
 which capacity  it  may be used  advan-
 tageously  in head-ache, chronic ophthal-
 mia, and  paralytic  affections of the face,
 mouth, and throat.
   Dose, and mode of administration. The
 medicine may be given in powder or in-
 fusion.   The  dose  as an emetic is from
 thirty grains  to  a  drachm.  The  leaves,
 on account of their greater mildness, are
 generally preferred as an errhine.   Three
 or four grains may  be snuffed up the nos-
 trils every night till the desired effect is
 produced.  They are often mixed with
 other substances in  order to  impart to
 them an agreeable odour.  The  Pulvis
 Asari Compositus, of the Edinburgh Col-
 lege, consists of three parts of asarabacca
 leaves, one of marjoram leaves, and one
 of lavender flowers.  It may be used as
 an errhine in the quantity of five  or six
 grains.                Geo. B. Wood.
   ASCARIS. (From aaxo^i^u, I leap.) A
 genus of intestinal  worms. (See Worms.)
           \/                  I-H.
   ASCITES.  (From owxoj, a water sac.)
 Hydrops  peritonai.   Hydrops abdominis.
 Abdominal Dropsy.
   Ascites is that form of dropsy in which
 the effused fluid is accumulated  within
 the cavity of the peritoneum.
   Under  the  term  Ascites, most writers
 include, also, what  are  denominated  en-
cysted  dropsies.   But as these have, if
any, only a very remote  relation to dropsy
                 38*
 properly speaking, consisting, for the most
 part, in an enlargement and morbid change
 of structure  of one  or other of the abdo-
 minal viscera, as the liver, spleen, ovaries,
 uterus, &c, connected, in the majority of
 instances, with the development of hyda-
 tids within its tissues, we have excluded
 them from our definition of ascites, and
 restrict the latter term to  a morbid accu-
 mulation  of  a seriform  fluid within the
 peritoneal sac.
   Ascites is  one of  the  most common
 forms  under  which dropsy presents itself.
 It may occur at any period of life from in-
 fancy  to  old age; but is  more frequent
 after than previous  to puberty,—and ac-
 cording to our own experience, females
 are  more subject to  it than  males.   A
 similar statement is made by  Hoffman
 and others.
   Symptoms.  In perhaps the majority of
 cases, ascites is the effect or sequel of chro-
 nic disease of the peritoneum and abdominal
 organs; and as it gives rise, at its commence-
 ment to no very peculiar or decided symp-
 toms, it often exists for a considerable time
 before the patient or his medical attendant
 is aware of the fact.  The first intimation
 of its actual occurrence is  often derived
 solely from the intumescence of the abdo-
 men, to which the effused  fluid, after  it
 has accumulated to a certain extent, gives
 rise.  In certain cases, nevertheless, par-
 ticularly those occurring in young, robust,
 and plethoric subjects, and succeeding to
 the action of cold, to the repulsion of acute
 eruptive diseases, or to the suppression of
 some habitual  discharge, ascites may oc-
 cur  suddenly and proceed with great ra-
 pidity.  Thus,  Stoll has known it to ap-
 pear in the course of a few hours after a
 draught of cold water taken while the in-
 dividual was in a state of profuse perspira-
 tion.  (Pralect. in divers,  morb.  chron.
 1788.)
  Ascites is  preceded and accompanied
 by a great diversity of symptoms, depend-
 ing  upon  the extent, seat, and character
of the lesions  by  which it  is  produced.
 Thus,  all the phenomena resulting from
 chronic diseases seated within  the abdo-
 men are met with in different cases; while
 in those cases in which the effusion is con-
nected with  affections of the  heart and
large blood-vessels, or with hydrothorax,
 the symptoms peculiar to these affections
 will also be present.  The phenomena im-
mediately dependent upon  the  dropsy of
the abdomen are confined, almost exclu-
sively, to those resulting from the physical
effects of the  effused fluid, its weight,
namely, and  pressure. 
450
ASCITES.  (Symptoms.)
  In general, as soon as effusion has taken
place within the peritoaeal  sac, the pa-
tient  complains of a feeling of more or
less  weight  and constriction about  the
lower portion of the abdomen. His urine
is diminished in quantity, and  becomes,
ordinarily, thick and high coloured,  and
lets  fall a sediment, differing in appear-
ance in different cases.   His thirst is in-
creased,—he becomes languid and indis-
posed to exertion of any kind,—his bowels
are generally costive, and the surface of
his body is dry and  parched.
   The  sense of weight and constriction,
which is always greatest on that side upon
which the patient  reposes, together with
the languor  and inertness of disposition,
augment with the progress of the disease.
There is also increased thirst,—the urine
becomes more scant,—the appetite dimin-
ishes,—flatulence and colicky pains, some-
times of considerable intensity,  are  fre-
quently complained of,—the breathing be-
comes difficult, and  the patient is occa-
sionally  affected  with nausea and vomit-
ing.   In proportion as the fluid accumu-
lates within  the abdomen, the parietes of
the  latter become  distended.  This  dis-
tension is first  perceived at  the hypogas-
trium, but gradually extends from thence,
until finally the whole abdomen becomes
enlarged, often to  an  enormous  extent.
When fully distended, the abdomen forms
an ovoid, tense and uniform tumour,—the
skin by which it is covered has a peculiar,
smooth, shining appearance,  and in many
cases  large distended veins  ramify in
every direction over its surface.   Occa-
sionally  the umbilicus is protruded by the
pressure of the fluid  within, so as to form
a tumour of considerable size.
   As the distension  of  the  abdomen in-
creases, the  pulse  becomes  small,  quick,
and  frequent,—the skin drier and more
parched, and the face assumes a pallid and
more or less bloated appearance.  In many
cases, the  patient experiences a sense of
pain or  soreness when the  abdomen  is
compressed; in others, he complains of an
acute fixed pain in some part of that ca-
vity, but more generally, of obscure shoot-
ing pains, occurring at irregular intervals.
   When the effused fluid has accumulated
to such  an extent  as to carry the intes-
tines into  the upper portion  of the abdo-
minal cavity, the descent of the diaphragm
being impeded by their pressure, the diffi-
culty of respiration becomes greatly in-
creased, and is often attended with a dry
irritative cough.  The patient is now often
unable  to lay down without  experiencing
the  most distressing sense  of impending
suffocation;  his sleep is  in  consequence
interrupted,  and his strength rapidly  di-
minishes.
  Ascites is occasionally attended through-
out with febrile symptoms of some inten-
sity ; ordinarily, however, the fever is less
marked and of a remittent type.
   Ascites may occur alone, or it  may be
complicated with  anasarca, hydrothorax,
or both.  When it is connected with dis-
ease of the heart or great  blood-vessels,
and when it occurs in patients of an ex-
tremely lymphatic temperament  or who
are labouring under considerable debility,
at an early period the feet will be found
to  become  slightly cedematous  towards
evening, while in the morning,  on first
rising from bed, the face and eyelids are
more or less bloated.  In other instances,
the oedema of the feet is more extensive
and continues during  the day, often ex-
tending to the legs and thighs; and when
the tumefaction of the abdomen is at its
height, even the  whole body may become
anasarcous.
   When ascites remains entirely free from
anasarca throughout the greater part of
its course,  it is ordinarily dependent upon
a lesion of the peritoneum, unconnected
with any considerable disease of either of
the abdominal or thoracic organs. Even
in  such cases, however, when the disten-
sion of the  abdomen has arisen to a con-
siderable height  more or less oedema of
the lower extremities is generally  pro-
duced, no doubt from the pressure of the
effused fluid, upon the veins and lymphat-
ics proceeding from those parts.
   The  intumescence of the abdomen in
ascites, is occasionally quickly  dispelled
and the patient  restored to health, by a
profuse diarrhoea; by an  increased dis-
charge from  the  kidneys; by a copious
perspiration (Bartholet, Tissot, Frank,
Quarin.  Journ. Hebdom. VI.);  or by a
hemorrhage  or vomiting, occurring spon-
taneously.  (Analen der Med. IV. 266.
Graham, Edinb. Med. and Surg. Journ.
XVII.  Forestus, Withering,  Monro,
Percival.)  A very interesting case of
ascites, of thirteen years' standing, is re-
lated by Dr. Graves (Dublin Journal of
Med. and Chem. Sc. Sept 1834.), which
was very quickly dissipated after the oc-
currence of a profuse mennorrhagia.
   In some instances, the swelling caused
by the protrusion of the  umbilicus  has
been known to burst and allow the effused
fluid to be discharged. (Schenkius, Bene-
voli, Forestus,  Despertes, Mead.) In
a few cases, according to Dalmas,  the
effused fluid finds its way  externally, in 
ASCITES.  (Diagnosis.)
451
consequence  of a communication  being
formed between the peritoneal cavity and
that of the intestines.  He saw one case
of this kind in an infant,  followed by a
perfect recovery; the patient dying sub-
sequently of a scrofulous affection.  Such
favourable terminations are, however, ex-
tremely rare.
   More  commonly,  as the distension of
the  abdomen  increases,  the  patient's
strength  rapidly  declines; the  functions
of the stomach become entirely suspended,
while those of the  lungs  are performed
imperfectly  and with the  greatest diffi-
culty,—the pulse becomes more and more
feeble and contracted,—the patient expe-
riences frequent attacks  of syncope,—he
is affected with  constant  drowsiness  or
complete coma, and death finally occurs
either from asphyxia or  cerebral conges-
tion.  A fatal termination sometimes takes
place very  suddenly and  unexpectedly.
In other cases, an acute inflammation is
developed within the thorax or abdomen,
which generally terminates in death, with-
in a very short period.  When acute peri-
tonitis supervenes in cases of ascites, the
effused fluid  is often very  quickly dimin-
ished in  quantity, or entirely removed pre-
viously to death. (Broussais. Phlegmas.
Chron.)   Sometimes, but very rarely, the
intumescence of the abdomen  suddenly
disappears, and dropsy of some other ca-
vity is as promptly  developed.  Andral
mentions a case, in which  ascites was
suddenly replaced by a serous effusion
within the brain, by which the patient
was quickly destroyed.
   The diagnosis of ascites  is to be de-
rived chiefly from the tense  and uniform
intumescence of the abdomen, and  the
fluctuation of the contained  fluid, which
may readily be  detected  if a hand  be
placed upon either side of the tumour, and
while one is kept fixed, percussion is made
with the other.  When, however, the ef-
fusion  is but small in quantity,  it causes
no very perceptible tumefaction of the ab-
domen, nor can a fluctuation be discovered
in the manner just  referred  to.   In such
cases, Tarral (Journ. Hebd.  No. 82.) di-
rects the percussion to  be made  at  the
lowest part of the abdomen with a single
finger, and within an inch or two of the
hand applied;  or one hand only may be
used, percussion being made with the in-
dex  finger,  while the abdomen is com-
pressed with  the others.    By this means,
Dalmas  assures us,  that he has been en-
abled to  detect very slight degrees of ef-
fusion which had escaped all other modes
of exploration.   In  the work of Piorry
(De la Percuss, mediate.), some interest-
ing observations will be found on the man-
ner of determining the nature and extent
of effusions into the peritoneal  sac, by
means of the pleximeter.
  Under ordinary circumstances,  the pre-
sence of ascites may be determined with-
out much difficulty,—there  being few af-
fections of the abdomen,  from which it
may not be readily distinguished by a cau-
tious  examination,  in connexion with the
history of the case.  Frank, it is  true, in-
forms us, that an accumulation of urine in
the bladder, causing the latter to become
distended and rise high into  the abdomen,
has been mistaken  tor ascites, and that
the operation of tapping has  actually been
performed under such circumstances. This,
however, could only have occurred from
gross ignorance or a culpable inattention
to the symptoms under which the patient
laboured.
  A tumefaction of the abdomen may arise
from  the development of a  gaseous fluid
within its cavity,—but the phenomena by
which it is accompanied are so distinct
from  those attendant upon ascites, that it
is scarcely  possible to  confound  the  one
with  the other affection.  Frank never-
theless refers to a case where a fluctua-
tion was apparently detected upon percus-
sion, but in which all the  symptoms were
caused by the  distension  of the  stomach
from gas.
   Dropsy of the liver and of the ovaries,
as well as the  other varieties of  incysted
dropsy, bear a close resemblance  in their
leading phenomena to ascites, especially
when  they are accompanied, as is  fre-
quently the case, with an eflusiou into the
peritoneal sac.   In incysted dropsy, how-
ever, the  fluctuation is either very ob-
scure, or not at all distinguishable : when
detected, it is confined to a particular part
of the abdomen, and is absent at every
other, or it  is found to  exist  in  different
situations corresponding with the changes
in the position of the body.  The intes-
tines are not situated in the  upper portion
of the abdominal cavity, as  in ascites, but
at the side opposite to that  on which the
greatest amount of tumefaction exists.  In
cases of ovarian dropsy, however, when
the diseased ovary has acquired a large
size,  the intestines are pressed  upwards
as in ascites, and a very distinct fluctua-
tion is often perceived upon percussion.
But all difficulty in determining the char-
acter of the disease is removed whenever
the physician has it in his power to ac-
quire an accurate history of its commence-
ment and progress.  In incysted dropsy, a 
452
ASCITES.  (Autopsic Lesions.)
tumour is, in general, first perceived with-
in the abdomen, which often moves from
side to side as the patient varies his posi-
tion.  This tumour is ai. first  small, but
very  gradually augments  in  size,  until
finally it fills the whole of the  abdominal
cavity. The general health of the patient,
at the same time, is but little, if at all im-
paired; the appetite ordinarily continues
good; the urinary secretion is  undimin-
ished ; the bowels are often regular; the
cutaneous exhalation natural;   until the
tumour acquires sufficient size to cause
distension of the  abdomen,  respiration is
unaffected, and there is no oedema of the
lower extremities, nor the slightest ana-
sarca.  In ovarian dropsy, the general ap-
pearance  of the patient  if we except the
tumefaction of the abdomen, is often that
of a perfectly healthy individual.
  It is impossible, we believe, for any well-
informed physician to confound  a state of
pregnancy with ascites.  The  diagnosis
may,  it is true,  be involved, occasionally,
in some degree of obscurity,  when the
two occur simultaneously, as is frequently
the case.  Thus, Mauriceau, Pujos, Smel-
lie, Baudelocque, and  the more recent
obstetrical writers, record numerous in-
stances of pregnancy attended  with ab-
dominal dropsy; and Frank even goes so
far as to  assert, that he has ascertained
from  long experience, that dropsy, espe-
cially under  the  form of ascites,  is fre-
quently one of the signs of pregnancy, or
at least  that hydropic  females have  a
greater tendency to become impregnated
at the commencement of the disease, than
when in  health.   Mauriceau  and other
writers refer to cases in which successive
pregnancies were accompanied with as-
cites. (Traite des maladies des femmes
grosses.  II.  59.)   In all  cases of intu-
mescence of the abdomen occurring in fe-
males, when any doubt exists  as to the
condition  of  the  uterus, a cautious and
skilful examination per vaginam will al-
ways enable the practitioner to determine
whether pregnancy does or does not exist.
■  The autoptical examinations of patients
who have died whilst labouring under as-
cites, present a very great diversity of
lesions in the abdominal and thoracic or-
gans.  The parts  most  commonly found
diseased are the peritoneum, the liver, the
spleen, the ovaries, the kidneys, the ute-
rus, the heart and  great  blood-vessels.
The peritoneum is very generally found
to exhibit symptoms of chronic inflamma-
tion ; it often presents an opaque whitish
or milky appearance, which has been com-
pared to the effect that would be produced
by long maceration in an aqueous fluid.
The membrane  is frequently thickened;
in other cases it  is covered with  small
membranous  flocirii which  adhere to its
surface by one of their extremities (Dal-
mas), or it is beset with innumerable mili-
ary tubercles:  it  is often  injected with
blood, and is occasionally covered with an
albuminous layer  of more  or less thick-
ness.  Adhesions between those parts of
the membrane that are in contact are very
commonly observed.   The lymphatic ves-
sels of  the  abdominal cavity are some-
times considerably enlarged; at others,
many of them are obliterated.  Morgagni
relates instances of both these states. The
abdominal muscles, in consequence of the
distension to which,  in  many cases, they
are for a long period subjected, are found
to be pale and reduced in thickness; in
other words, in a state of complete atrophy.
   While the indications of a morbid con-
dition of the peritoneum are seldom pre-
sent without being accompanied with a
serous effusion, into the cavity of the ab-
domen, to a greater or less extent, there is
no one  of the other lesions  met with in
cases of ascites, which does not frequently
occur without the least trace of effusion
being present; the latter likewise often
occurs without our being able  to detect
any important morbid change in either of
the abdominal or  thoracic organs.  It is
evident therefore, that the lesions of these
organs  are only indirectly concerned in
the production of ascites; hence it would
be an unnecessary labour to enter into a
minute  detail of them  upon the present
occasion.  It will  be  proper, however, to
say a few words in relation to the fluid ef-
fused within the peritoneum. This varies
in quantity and appearance in different
cases.   In  some, the peritoneal sac con-
tains but a few pints, while in others it is
distended by many gallons.  In perhaps
the majority of cases, the fluid  is colour-
less or  of a light yellowish tint, perfectly
limpid  and  without any decided smell.
Upon the application of heat or the addi-
tion of an acid,  it  partially coagulates.
Occasionally,  it is of a deep  yellow or
greenish colour, and still more rarely, dark
brown, or even black.  In some cases it is
turbid,  of a  milky appearance,  and con-
tains more or less albuminous floculi; in
other instances it is of the  consistency of
thick mucilage, or even gelatinous.  Cases
are recorded in  which it is said to have
exhaled a highly fetid odour, even when
discharged by an operation during the life-
time of the  patient   It frequently con-
tains numerous  hydatid cysts, which are 
ASCITES.  (Pathology.)                         453
likewise found adhering to the surface  of
the peritoneum, especially  where it en-
velopes  tlie different organs. (Scoutet-
ten's Pathol.  Anat. of the  Peritoneum.
Lond. Med. and Phys. Journal.  1824-5.
Clinique Medicale, par  G. Andral, Fils.)
  Pathology.  Referring to the general ar-
ticle Dropsy for all details in relation to the
pathology of ascites, we shall on the pre-
sent occasion  merely advert to  the  more
prominent lesions upon which the produc-
tion of the disease would appear to depend.
   1. Ascites is occasionally suddenly de-
veloped, and  the  abdomen becomes dis-
tended with great rapidity.  (Rust's Ma-
 gazin.  XXIX. 468.)  These cases gene-
 rally occur in  young, robust, and plethoric
 subjects, either soon after the patient has
 been subjected to  the  influence of cold
 when in a state of profuse perspiration, or
 labouring under exhaustion from fatiguing
 labour or exercise; or else,  subsequently
 to the cessation of some habitual evacua-
 tion. This constitutes the acute, idiopathic,
 sthenic or inflammatory ascites of differ-
 ent writers.   The  effusion  into the  abdo-
 men in such cases evidently depends upon
 that particular grade  of  inflammation,
 nearly bordering upon the acute, occurring
 in the  peritoneum, which,  whenever it
 takes place in either of the serous  mem-
 branes, very  generally gives rise  at an
 early period to a  morbid  discharge of a
 seriform  fluid.  Few opportunities,  how-
 ever, are presented for autopsical exam-
 inations in this variety of ascites, it being,
 in general, very  readily  removed  under
 an  apppropriate treatment  When such
 opportunities,  however,  have  occurred,
 some portion  of the peritoneum has been
 found to be morbidly injected with  blood,
 and slightly  opaque:  in  other  instances
 an albuminous exudation of moderate  ex-
 tent has existed; while in others, neither
 the peritoneum nor abdominal organs have
 presented any very decided change from
 their normal condition.
   When ascites occurs under the circum-
 stances just referred to, the pulse is usu-
 ally tense and active, sometimes full, but
 more commonly contracted.  The skin is
 hot and  dry, the tongue  white, and  the
 countenance  is frequently  more or  less
 flushed.  The blood exhibits, when drawn,
 a huffy appearance, and the urine coagu-
 lates when heated.  There is great rest-
 lessness,—wakefulness or disturbed sleep,
 —a feeling of great anxiety and of ful-
 ness or tension about the abdomen.   The
 latter is often sore to the  touch: in  many
 instances the  patient complains of an ob-
 scure pain seated in some portion of it,
and in others, of acute shooting pains, oc-
curring at intervals.
  To this variety of ascites we may refer
those cases which occur in the course or
towards the termination of acute inflam-
matory affections,  particularly of the ab-
dominal organs; those which succeed to
the repulsion of certain eruptive diseases;
to contusions and other injuries of the ab-
domen (Mead. Pracepta et monita  me-
dica. VIII. 30.);  and to protracted  and
difficult  parturition.  (Osiander, Stoll,
Selle,  Portal.)
  2. Ascites is found to occur much more'
commonly in those who are labouring un-
der  some chronic  affection  of the abdo-
minal organs.  This variety of the disease
is chiefly met  with in persons of intem-
perate habits,—those who have been long
subject to affections  of the  stomach  and
bowels, or who have suffered from repeat-
ed attacks of  intermittent fever, &c.—or
those who reside in unhealthy districts or
localities, or whose diet is composed prin-
cipally of unwholesome  articles.   This
constitutes the symptomatic, asthenic or
passive ascites of many authors, by whom
it is either referred to obstructions of the
viscera or to debility.
   There can be little doubt  that in a few
cases, particularly in those connected with
certain hepatic affections, an impediment
or obstruction to the venous circulation is
really present, and that in this manner
the  effusion is produced,—but in by far
the  majority of cases no such obstruction
can be shown to exist.  It  is likewise to
be remarked, that in persons who have la-
boured for a  long period  under very ex-
tensive disease of the liver, spleen, uterus,
&c, by which complete disorganization of
these viscera  has been produced, not  the
slightest trace of  serous effusion into the
abdomen has  taken place.   It  is hence
 evident that no  direct connexion exists
 between the organic lesions above referred
 to and the production of ascites, when they
occur in the same individual.   It is  only
 when inflammation has extended from the
 affected organ to  its peritoneal covering
 (Ayre), that  a morbid effusion  of serum
 into the cavity  of the abdomen is pro-
 duced.  More or  less serous effusion  is
 well known to be the most common at-
 tendant on chronic inflammations of the
 peritoneum (Broussais) ; and upon dissec-
 tion in fatal cases of the variety of ascites
 of which we are  treating,  the  most un-
 equivocal indications of a chronic phleg-
 masia  of that membrane are almost inva-
 riably  present  Our view  of the patho-
 logy of abdominal dropsy connected with 
454
ASCITES.  (Treatment.)
visceral disease, is confirmed by the fact,
that the development of acute peritoneal
inflammation is not unfrequently,  in this
variety of ascites, the  cause  of  death,
which is likewise the case in well-marked
chronic peritonitis. (Broussais.)
  The present variety  of  ascites is al-
ways preceded for some time by the phe-
nomena  indicative of disease of one or
other of the abdominal organs.  The effu-
sion takes place slowly, and consequently
the tumefaction of the abdomen is effected
very gradually.  The disease is  seldom
attended by any very decided febrile ex-
citement; the pulse is commonly neither
tense nor active; the temperature  of the
skin is but little if at all increased;  and
the countenance  is often sallow, or it has
even a deep icteric  hue.   Occasionally,
however, the patient experiences  in the
course of the day a slight attack of fever,
preceded by a sense of chilliness.  The
tenderness of the abdomen upon pressure
is less than  in the preceding variety; but
colicky pains,  often  of considerable  vio-
lence, are frequently experienced.  The
languor and inertness of the patient are
strongly marked,—there is ordinarily great
depression of muscular strength, and the
emaciation of  the body is  usually very
considerable.
  3. That dropsical effusion into the ca-
vity of the  abdomen is occasionally de-
pendent upon an obstruction to the venous
circulation,  there  can now  be very little
doubt The fact was pointed out by Mor-
gagni and the writers who immediately
succeeded him,—while Lower, by direct
experiment, proved that when the passage
of the blood through the veins is arrested,
serous effusion  results.   He tied the infe-
rior cava in animals,  and  in every case
found  they became quickly affected with
ascites.  It is  true, that by many highly
respectable  pathologists, the  dependence
of abdominal dropsy, in any  cases, upon
venous obstruction, has been denied,  and
similar experiments  to  those of Lower
have been performed and no effusion took
place; yet, the observations  of numerous
and  cautious  observers, of  a late date,
prove very satisfactorily that an obstruc-
tion to the  circulation  through the veins
does very generally give rise to dropsical
effusion,  and that such obstruction is fre-
quently present in cases of ascites.  Thus,
Bouillaud (Arch. Generales. 1823-24.)
found that in the greater number of abdo-
minal  dropsies  which  fell  under his no-
tice, connected with disease  of the liver,
the calibre of the vena porta was more or
less contracted, or even  obliterated.  He
likewise states that the obstacle to the
free circulation of the blood  may occur
either in the liver itself, in the trunk of
the portal vein, or in one of the principal
branches which terminate in it A similar
statement  is  also   made  by  Reynaud.
(Journ. Hebdom.)  The inferior cava is
likewise occasionally found contracted in
cases of ascites attended with oedema of
the lower extremities.  (Dalmas.)
  The  impediment to  the venous circula-
tion giving rise to abdominal dropsy, may,
in other cases, occur from disease of the
right  side of the heart, or of the lungs;
and, occasionally, it is probably to be re-
ferred to the pressure, upon the ascending
cava, of tumours developed within the ca-
vity of the abdomen.
  The symptoms of the variety of ascites
under consideration, are similar to those
of the variety last mentioned.  According
to Reynaud, when the obstruction occurs
in the vena porta, a dilatation of the su-
perficial veins of the abdomen is produced,
which statement, if its accuracy shall be
established by future observations, is high-
ly important in regard  to the diagnosis of
those  cases. (Stokes.  Clinical Lectures,
in Lond. Med. and Surg. J. April, 1834.)
  4. The dependence  of ascites upon le-
sions of the kidneys, has been very fully
established by Bright, Christison, Gbe-
gory, Dance, and  Rayer.  A very in-
teresting case of this variety of ascites is
related by Krukenberg. (Jahrbucker der
Klinik  zu Halle.  II. 373.)  For further
particulars on this  subject the reader is
referred to  the  articles Anasarca and
Dropsy.  The  symptoms in these cases
da not differ materially from those of the
two preceding varieties.
  Treatment.  The treatment of ascites
will vary in different cases, according to
the nature of the lesions with which the
effusion  into the abdomen is connected,
the extent and period  of the. disease, and
the age, constitution,  and habits of the
patient.
  The  morbid  accumulation  of serum
within the peritoneal  sac,  being merely
an  effect of some preceding organic af-
fection, it must be evident that until the
latter is removed, it is in vain to expect
a permanent removal of the former.  In
many, perhaps in the majority of instances,
the organic disease upon  which  ascites
depends is incurable, as when a complete
change  of structure has been produced in
the tissues of the heart, lungs, liver, kid-
neys, &c, or when the cava or other im-
portant  venous  trunk has become greatly
contracted or completely obliterated.  In 
ASCITES.  (Treatment.)
455
 such cases, all that can be done by the aid
 of medicine  is to ameliorate the more ur-
 gent symptoms, and in this manner con-
 tribute to the comfort of the remaining
 period of the patient's existence.
   In the early stage of nearly all the va-
 rieties of ascites,  but especially of that
 denominated acute  or idiopathic, bleeding
 constitutes an important remedy.  When
 judiciously resorted to, and carried  to a
 proper extent it will  frequently produce
 within a  short period  an increase of the
 urinary discharge, and a rapid diminution
 in the intumescence  of the  abdomen;
 while, at the same time, it relieves the ir-
 ritated or  inflamed condition of the peri-
 toneum by which the  morbid effusion is
 kept up, and thus prevents  a subsequent
 return of  the dropsy.
   The beneficial effects resulting  from
 the  free abstraction of blood in cases of
 acute ascites, are pointed out by Backer,
 Sauvages, Mead,  Monro,  Portal,  and
 Frank ; but  its importance is more parti-
 cularly insisted upon by Rush, Breschet,
 Geromini, Chauffard,   Ayre,  Parry,
 Graham,  and the  more  recent  writers.
 In many cases, it is in  vain to expect any
 decided benefit  from  the exhibition  of
 purgatives and diuretics previously to free
 depletion  either by the lancet or by the
 extensive  application of cups or  leeches
 over the abdomen. Local depletion, though
 productive of the best effects in  ascites,
 has  been   strangely overlooked  by  the
 generality of practitioners:  in  numerous
 instances a resort to it will supersede  the
 necessity  of  abstracting blood from  the
 arm; and  in all decidedly acute cases, it
 should invariably follow the use  of the
 lancet
   It is not merely, however, to the acute
 variety of abdominal dropsy, that the  use
 of general  and topical  blood-letting is to
 be restricted. In those  cases in which the
 effusion into  the  peritoneum  is  compli-
 cated with disease of the heart, or with a
 chronic affection of some* other organ, it
 will  likewise be  found often strikingly
 beneficial.   Even when the effusion is de-
 pendent upon a permanent obstruction to
 the venous circulation, bleeding will more
 effectually check its increase, and relieve
 the distressing sense of weight and dis-
 tension under which the patient labours,
 than  almost any other remedy.   In such
 cases, as a  general rule, the application of
 cups  and leeches to  the abdomen is to be
 preferred to bleeding from the arm.
  Ever since the days of Hippocrates,
purgatives have been a favourite remedy
in  ascites;  and notwithstanding their de-
 nunciation by Fordyce, they are  unques-
 tionably beneficial in many cases,  particu-
 larly such as produce copious watery eva-
 cuations, as the  neutral salts, gamboge,
 elaterium, &c.  In  the acute variety of
 the disease, when no considerable irrita-
 tion of the  alimentary canal  is  present
 they often prove an excellent adjuvant to
 bleeding.  The purgative which we pre-
 fer, under  such  circumstances,  is  the
 cream of tartar in combination with jalap.
   Most  writers speak favourably of the
 effects of cream of tartar in nearly all the
 varieties  of abdominal  dropsy.  (Frank,
 Jahn,  Richter,  Ferriar.)   When  ad-
 ministered in large doses, it not only pro-
 duces  copious  fluid  evacuations from the
 bowels, but also an increased flow of urine.
 Ferriar  states that when in his hands
 the cream of tartar proved successful, its
 diuretic effects were evinced within twen-
 ty-four  hours after  commencing with its
 use.  He generally found it to diminish
 the swelling very rapidly;  more  quickly
 than the increase  in the amount of urine
 discharged would  have  led him to antici-
 pate.  He was in  the habit of administer-
 ing it in conjunction with digitalis.
   Bang and Selig  prefer the soluble salt
 formed by the union of boracic acid with
 cream of tartar (Act. Reg. Societ. Med.
 Havn.  III.);  while the favourite  pre-
 scription of Dr. Physick is the tartrate of
 potass made by adding one part of  carbon-
 ate of potass to two of cream of tartar:
 this we have ourselves  employed in seve-
 ral cases of ascites, with decided  advan-
 tage.  The  dose  is from one to three
 drachms, every three hours.
   As a purgative in abdominal  dropsy,
 Ayre prefers gamboge  to all others.   He
 directs it to  be given in the dose of  from
 four to five grains  triturated with  the
 same quantity of aromatic powder and a
 small quantity  of  cream  of tartar.  We
 have administered the  gamboge in doses
of two or three grains  combined  with a
drachm or two of cream of tartar, and
have often found it to reduce the swelling
in a very short period.   It is  not how-
 ever, well adapted  to the acute cases  of
the disease, and is  altogether inadmissible
 in those attended with any degree  of irri-
tation of the stomach or bowels.
   Of late years, the elaterium has been
extensively  employed  in ascites.   It is
confessedly the most  powerful hydrogogue
 we possess, causing a reduction  in the size
of the abdomen, with more quickness and
certainty than  any  other remedy with
which we are acquainted.  Like all other
 very active remedial agents, however, it 
456
ASCITES.  (Treatment.)
requires  to  be used with  great  caution.
Whenever the bowels are in a state of ir-
ritation, the elaterium is a dangerous  and
improper remedy.  The same is also true
in all cases, when it is administered at too
short intervals,  or  for too  long a period.
Hoffman and Sauvages (Nosol. Melh. II.
504.) long since pointed out the mischiev-
ous effects  resulting from  the imprudent
use of drastic purgatives in ascites.  In-
dependently of  the violent inflammation
of the bowels occasionally produced  by
them, dropsical  eflusion into the abdomen
so frequently succeeds  to a diseased con-
dition of the alimentary canal,  that we
are persuaded, notwithstanding the rapid
decrease in the  swelling, which  so gene-
rally takes place during their employment,
they  cannot fail to augment  in many
cases, the lesions upon which the dropsy
depends, and accelerate the fatal  termina-
tion.  By these  remarks, we do  not wish
to be understood as reprobating entirely
the employment of active hydrogogue re-
medies  in ascites,  but only as cautioning
against their indiscriminate and excessive
use.  In his Hospital facts and  observa-
tions, Dr. Bardsley has detailed several
cases of ascites which were cured by the
use of veratrea.  In  the dose of half a
grain, every four hours, at first,  and sub-
sequently of one grain  twice a day,  this
substance was found to produce  repeated
watery evacuations, and in a short time
to remove entirely the  intumescence of
the abdomen.  In its effects, the veratrea
appears to bear  a very close resemblance
to elaterium. (Med.-Chirurg. Rev. Oct.
1830.)
   The Kahinha root  a South American
production,  has  within  a few years been
strongly urged upon the attention  of the
profession, as a remedy in the abdominal
and other forms of dropsy.  It was  em-
ployed by Dr. Francois in several obsti-
nate  cases  of ascites, with complete suc-
cess.  (Gaz. Med.  et Gaz. des Hbpitaux.
1832.)  When given in full doses, the ka-
hinha acts powerfully both  upon  the  kid-
neys  and bowels.  Of the extract, from
twelve  to  thirty grains may be  given,
commencing, however, with small doses,
and gradually increasing their strength;
or a  decoction may be  made by boiling,
for ten minutes, two ounces of the bark,
previously macerated for forty-eight hours,
in eight ounces  of water.   One half of
this quantity is to be taken at once,  and
the remainder  in  the  course of two or
three hours.   The strength of the decoc-
tion is to be increased, subsequently, until
it causes a marked augmentation of the
urinary and intestinal secretiona
  In addition to the articles already men-
tioned, we may remark, that nearly every
other enumerated on our list of purgatives,
whether mild or drastic, has, by different
writers, been  proposed in  the  treatment
of this and the other forms  of dropsy. But
although Rush refers to two cases of as-
cites cured by an ounce of castor oil taken
in the course of the day, we can, in gene-
ral, expect  but little permanent benefit,
excepting from those  purgatives  which
produce copious watery discharges.  To
procure simply an opening  of the bowels,
or to relieve them from an accumulation
of feces, where hydrogogue cathartics are
not thought advisable, calomel or any other
mild evacuant may be resorted  to; but
when our object is to  cause a discharge
of the effused fluid by acting upon the ex-
halants of the intestines,  these  articles
can seldom be depended upon.
  From the circumstance, already referred
to, of ascites having been noticed, in many
instances, to disappear after the  occur-
rence  of spontaneous  vomiting, emetics
have been resorted to  and  recommended
as an important remedy in its treatment,
and numerous imposing authorities might
be cited in proof of their efficacy. (Boer-
haave, Monro, Sen.)  Duverney reports
a case  cured by emetics, in an  individual
in whom tapping had been  repeated seve-
ral times,—and a somewhat similar one is
cited by Monro.  Simmering assures us
that he has obtained from the use of eme-
tics  alone, an almost  instantaneous re-
moval  of ascites.  Itard likewise states
that he has seen cases -that had resisted
the use  of drastic purgatives  and diu-
retics,  cede  to the  repeated employment
of emetics.
  It is in those cases of abdominal dropsy
which succeed to the action of cold upon
the body, and  to the sudden cessation of
cutaneous eruptions, that  the  effects of
emetics are said to be  the  most promptly
beneficial.
  Of the remediate powers of emetics in
ascites, we are unable to speak from our
own experience,  having never employed
them.  We have, however,  derived the
most decided advantage from the employ-
ment of nauseating doses of tartarized an-
timony, in the acute variety of the dis-
ease,   subsequent  to  active  depletion.
Frank, also, gives his testimony in favour
of the effects of antimonials, when admin-
istered under similar circumstances. We
have generally prescribed the emetic tartar 
ASCITES.  (Treatment.)                        457
in combination  with nitre, and we have
reason to believe that its efficacy is there-
by increased.
  The employment of the nitre by itself,
as a remedy in acute ascites, has the sanc-
tion  of some of the  most  distinguished
writers on tlie disease.   Rush states, that
by a  wine-glassful  of  a solution of two
ounces of nitre in a pint of water, repeated
three times a day,  he cured two cases of
abdominal dropsy; and  the late Professor
Dorsey considered  it to be,  in the acute
variety of the disease, one of our very best
diuretics.  (M.  S. Lectures.)  To  avoid
inconvenience from  its use, it is recom-
mended to begin with small doses, which
are to be gradually increased;  and should
it prove ineffectual  after being continued
for two or three weeks,  its further em-
ployment is to  be relinquished.  Accord-
ing to Dorsey, it rarely proves actively
diuretic until the dose amounts to three or
four drachms in the day.
   Nearly every article on the  list of diu-
retics has been  recommended  for the re-
moval of ascites: from few,  however, will
any permanent good effects be derived.
The  cream  of  tartar and nitre appear to
be the  diuretics best  adapted to  acute
cases; in the more chronic, some benefit
will occasionally result from the adminis-
tration of the digitalis  and squill.  The
digitalis is only adapted, however, to cases
of ascites occurring in persons of a lax
fibre  and pale  countenance, and attended
 with  a  cold skin and  feeble or intermit-
tent pulse.  (Withering, Maclean.)  By
 Blackall  and Hamilton,  it  is  recom-
 mended as  peculiarly beneficial in abdo-
minal dropsy succeeding to scarlatina.
   A strong  decoction of Chimnphila um-
 bellata is recommended by Somerville,
as powerfully diuretic.  Sir Walter Far-
quhar tried it in a case of ascites, with
striking advantage; and Marcet employ-
ed the extract of the plant  in the dose of
fifteen grains, with the  best effects.
   The infusion of horse-radish is spoken
of by many eminent  practitioners, as a
diuretic  of  very   considerable   efficacy.
(Heister.   Compend.  medicin. pract.  j
xviii. 212.)   A case  of ascites,  of long
standing, is referred to by Eberle (Pract.
Med. II. 443.), which  was  removed in a
short time  by its  use.    Sciimidtmann
states that he has frequently employed the
horse-radish, with good effects, in  abdo-
minal dropsy,  after other  diuretics had
failed.  " It appears to me," lie remarks,
"that modern practitioners have too much
overlooked this powerful remedy in obsti-
   vol. ii.          39
nate cases of the  disease." (Hufeland's
Journal. LXX. 71.)
  The efficacy of whatever diuretic we
may employ, will be greatly increased by
the patient making use,  freely,  at the
same time, of diluent drinks, particularly
such as have the property of increasing
also the action of the kidneys: the best of
these are,  probably, fresh whey, infusion
of parsley-root or of juniper berries;  but a
long list,  in  addition to  these,  present
themselves for the choice of the practi-
tioner.  Caution should, however, be ob-
served,  that in acute cases of ascites, or
in those attended with inflammation, and
an irritable state of the system,  all stimu-
lating fluids be cautiously proscribed.   ,
  The production of diaphoresis has been
proposed as a means of removing ascites,
both by the exhibition  of internal reme-
dies, and by the use of the warm or va-
pour bath, or by a bath formed  of heated
sand or common salt.  The warm and va-
pour baths, when properly timed, will un-
questionably be found a beneficial remedy
in many cases of abdominal dropsy, espe-
cially in such as result from the action of
cold (Richter), or which succeed to mea-
sles and scarlatina, or to the sudden repul-
sion of cutaneous eruptions.  In the latter
cases, Frank considers the warm bath to
be  one of our most efficient remedies.  It
will likewise be  found  beneficial in  ab-
dominal dropsies  connected with chronic
disease of the peritoneum and liver.
   Of internal diaphoretics, we can say but
little from our own experience,  unless we
may consider as such, minute doses of tar-
tar  emetic,  to the  remedial  effects of
which we have already alluded.
   In the chronic variety of ascites, espe-
cially when attended with soreness of the
abdomen  and occasional paroxysms of
pain, we have found the compound pow-
der of ipecacuanha very generally useful.
   By  a few  writers on ascites, mercury
has been  extolled as a remedy of great
efficacy, especially when the effusion into
the abdomen is attended with hepatic dis-
ease.   The recommendation of mercury
in  these  cases, appears to us, however, to
be founded altogether upon an  erroneous
 view of the pathology of the disease, and
 of the operation of the  remedy.  That
 cases  of abdominal dropsy  do  occur,  in
 which the alterative effects resulting from
 a properly conducted mercurial  course are
 decidedly advantageous, we are well con-
 vinced ; but as a general rule, and when
 given in large doses, or so  as to excite  a
 copious salivation, mercury appears to  us 
458
ASCITES.  (Treatment.)
to be a doubtful, often an injurious, remedy
in all the forms of dropsy.  " Under a sa-
livation," remarks Ayre, " the urine  be-
comes  charged with serum.   Any condi-
tion of the system, therefore, approaching
even to a state of salivation, must be inju-
rious, by the tendency it must have to in-
crease that morbid state of the body which
is nearest  allied to the  hydropic one.
Hence, the mercurial salivation has been
numbered amongst the remote causes of
dropsy; and the resemblance between  the
dropsical and mercurial excitement thus
established, by the common  resemblance
of the urine in these states, goes far to
prove  this connexion; and it is not im-
probable, that the mercurial inflammation,
when  considerable,  may survive its spe-
cific cause, and degenerate, at length, into
the purely hydropic state.  When, how-
ever, mercury is given in minute doses,
so that these its specific morbid effects  are
not produced, it  is  capable of becoming
highly useful." (Researches on the nature
and treatment of dropsy.)
  Mercurial frictions over the  abdomen
have been resorted  to in ascites, with ap-
parently decided advantage.  Laennec in-
forms us, that by their employment he  has
succeeded  in curing cases after the reme-
dies usually relied on had entirely failed.
(Revue Medicale. Mai, 1824.)
  The beneficial effects  of frictions over
the abdomen, with liniments composed of
diuretic articles, have within a few years
been noticed by  various European physi-
cians,  by whom numerous cases of ascites
are reported, in which an entire cure was
obtained by this means.  Guibert (Revue
Med.  Sept. 1828. p. 349.) employed as a
liniment, the following: tincture of squill,
of digitalis, and of colchicum seed, of each
half an ounce, combined with one ounce
and a  half of camphorated oil.   This was
rubbed over the abdomen, with a flannel
cloth,  four or five times  in the course of
the  day;  the  frictions  being continued
each time  from  five to twenty minutes.
At the same time, he administered inter-
nally a combination of equal parts of squill,
digitalis, and nitre.
   This plan of treating abdominal dropsy
by frictions with diuretic liniments, Gui-
bert considers to be peculiarly efficacious,
and he attributes to it, mainly, the suc-
cessful result of the cases which  he de-
tails.  In all of them, as well as in others
subjected to the  same plan,  the dropsical
 swelling was removed with striking ra-
 pidity.  In  idiopathic  ascites,  he  is of
 opinion that it will be almost invariably
 successful.  He,  however, remarks, that
it should not be resorted to until after the
phlogistic condition of the system is re-
duced  by appropriate remedied  Brera
and Itard both bear testimony to the diu-
retic effects produced by the squill when
applied by  frictions  to the  skin.    By
Stcerck, simple oily frictions are highly
extolled.
  Blisters to the abdomen are unquestion-
ably a  useful remedy in many cases of as-
cites ;  especially in those dependent upon
chronic inflammation  of the peritoneum.
By a few writers,  blisters are directed to
be applied to the  inside of the  thighs, in
preference to the  surface  of  the belly.
Richter  refers to a case  in which, when
thus applied,  they caused  the removal
of an ascites which had resisted all other
remedies.
  The application of pressure to the ab-
domen, in the  treatment of dropsy of that
part, either subsequent to the operation of
paracentesis, or previously  to  this being
resorted  to, is an old practice, which,
though neglected for a long period, has
lately  been revived,  and  the evidence
presented in its favour, is in the highest
degree respectable.   Recamier, Husson,
Moulon and Godelle de Soissons, have
employed it with the most decided advan-
tage.  Husson states that he has succeed-
ed  in  completely  removing  ascites by
pressure alone. (Ann. Med.  Chirurg.) A
case is recorded in the Annali di Medicina,
for 1827, in which Professor Speranza, of
Parma,  effected  a perfect  cure by the
same means;  and more recently, Briche-
teau,  in a memoir inserted in the Ar-
chives Generales for 1832 (XXVIII.  75.),
has  adduced  a  number  of instances in
which its efficacy was strikingly evinced.
Under its employment, an increase of the
urinary discharge, with rapid  diminution
of the swelling,  is said  very  quickly to
occur.  When the effusion into the abdo-
minal  cavity is unaccompanied by disease
of the  thoracic organs, the pressure should
be made with  a laced bandage, accurately
fitted to the body, and extending from the
lower  part of the chest to the pelvis.- Ac-
cording to M.  Fenioglio, a cure of ascites
is not  obtained by means of pressure,  with-
out a certain degree of peritoneal inflam-
mation being excited  (Gaz.  Med.  III.
588.); an opinion which,  to say the least
of it,  is extremely hypothetical.
  The removal  of ascites has been at-
tempted by the introduction of the vapour
of wine into the cavity of the peritoneum.
In  the Annates de la Med. Physiol., two
cases are related, the cure of which is at-
tributed to this plan of treatment.  And 
ASCITES. (Treatment.)
459
L'Homme, in the early part of the year
1827, communicated to the Academy of
Medicine at Paris, the history of an obsti-
nate case,  in  which, after  having been
subjected to all the usual remedies, with-
out  any decided  benefit,  the  disease
was permanently removed by the  intro-
duction  into the abdomen, of the  vinous
vapour.  The latter was repeated sixteen
times, at different intervals, without any
particular  inconvenience  to the patient,
if we except the production of slight co-
licky pains.  This gentleman resorted to
the same  plan of treatment in another
case,  of long  standing, but without  the
least benefit. (Revue Med. 1827.)  In  the
Annates de la Med. Physiolog. for August,
1831, some  cases of ascites are related,
which were treated by the introduction
into the peritoneal cavity, of nitrous oxyde
gas: in  one, only, was a cure effected.
  The above practice is one, we  must con-
fess, that we should not feel inclined to
follow ourselves, or  to  recommend to
others.
   From the erroneous opinion, which at
one period so  extensively prevailed, that
the production of ascites, in common with
the other  forms  of  dropsy,  is invariably
dependent,  either directly or indirectly,
upon a state of exhaustion or debility,  the
exhibition of tonics was formerly, and by
many practitioners  even of the present
day is, considered to be indispensable to
its removal.  That under certain circum-
stances, the cautious administration of to-
nics will be productive of beneficial  re-
sults  in abdominal  dropsy,  is  admitted;
but as a general rule, their  use is not in-
dicated; on  the  contrary, they would in
numerous  cases  be  productive  of injury.
In  the  commencement and early  period
of the majority of cases, especially, they
would be decidedly prejudicial.  The  ac-
curate discrimination of the particular  cir-
cumstances which render the employment
of tonics proper, can be made  only after
close and repeated observation at the bed-
side of the sick:  all general directions on
this head would be more liable to mislead
than to  assist  the judgment of the inex-
perienced practitioner.
  To evacuate the fluid accumulated in
the abdomen,  and thus get rid at once of
the swelling produced by it, a  very obvi-
ous means presents  itself, the puncturing,
namely, of  the  abdominal  parietes,—an
operation which is  readily performed, is
productive of little  or  no  pain  to the pa-
tient, and,  under ordinary circumstances,
unattended with danger. Experience, how-
ever,  has  shown,  that although in  this
manner  we  can  without difficulty remove
the effused fluid, the benefit obtained is
but temporary,  the abdomen  becoming
again distended, and so rapidly, that  the
very operation itself would appear to in-
crease the extent of the effusion: hence,
it has to be repeated frequently, and each
time at a shorter interval.  Cheselden,
Stcsrck, Mead, Scott, Villermay, and
other writers (Edinb. Med. Communic.
VI. 441.  Revue Med, July, 1828.   N.
Samml. Med. Wahrnemungen. III. 94.),
present cases in which the operation was
repeated from forty to sixty times in  the
same patient; and similar instances have
fallen under our own notice.   They very
clearly prove that  the operation, though
ordinarily without danger, is  productive
of no permanent benefit   A resort to it
is, nevertheless, strongly advised by many
respectable physicians.  Fothergill, Hun-
ter, Bertrand, Baker, and  Mead,  ad-
vise, as a means  of deriving the greatest
benefit from the operation, its employment
at an  early  period of the disease;  and
cases are recorded by them, as well as by
Frank, Dessault, Lenten, Richter, and
Schmidtmann, in which  a radical cure
was thus effected.   The entire number of
such cases is, however, extremely small:
in the great  majority of instances, a pal-
liative effect  is all that can be anticipated
from it.  Camper assures  us that out of
one hundred  cases in which the operation
of paracentesis was performed by him, he
could not refer to  more than six which
were completely  cured;  and   Portal
makes a somewhat similar confession.
   Occasionally, in  ascites, the protruded
navel gives way,  in consequence of the
pressure from within, and allows the fluid
to escape from the abdomen; in this man-
ner a permanent cure has been known to
result.  Mead (Monita Medica) was con-
sulted in  a case  in which the patient a
female, being in a state of extreme  ex-
haustion, he  was deterred  from perform-
ing the operation of paracentesis, and pre-
dicted a fatal termination of the disease:
two openings, however, occurring near
the navel, from the first, twelve pints of
fluid were discharged, and, on the ensuing
day, six pounds from the other,—and the
health of the patient became perfectly re-
stored.  In consequence of these sponta-
neous cures after ruptures  of  the umbili-
cus, Sims (Mem. Med. Soc. Lond. IV. 472.)
and others have proposed to perforate that
part, and to  allow the fluid  gradually to
discharge itself during several days, with-
out introducing a canula.   Darwin (Zoo-
nomia) has seen this operation performed
twice, with  less inconvenience,  and, he
conceives, with more advantage to  the 
460
ASCITES.—ASCLEPIAS.
patient, than would have  resulted  from
the ordinary mode of tapping.  Two  in-
teresting  cases  are related by  Mr. Os-
wald  (London Med. and Phys. Journal.
April,  1826.), in which good effects, appa-
rently, resulted from allowing the opening
made  by the trochar to remain unclosed
for some  time, so as to permit a  constant
draining off of the effused fluid.
   Although we can but rarely expect a
permanent  removal of ascites to  result
from the operation of paracentesis, in what-
ever way it may be performed, a  resort to
it is, nevertheless, in many instances,  ab-
solutely necessary.  When the distension
of the abdomen is very considerable, the
patient is not only incommoded greatly by
the weight  and pressure of the contained
fluid,  but  experiences  often  the utmost
distress  from  the impediment which it
presents to the freedom of respiration,—
and the relief obtained by drawing off the
water  is  immediate and  striking.   It is
probable also,  that the mere distension of
the abdomen,  not only keeps up and aug-
ments the morbid state of the peritoneum,
upon which the effusion depends, but pre-
vents,  also,  to a very considerable degree,
the  beneficial operation of the remedies
administered:  thus, Richter (Anfangs-
grunde der Wundarzneikunst.  V.  124.)
and Schmidtmann  (Op. Cit. p. 77.) both
remark that they found the very remedies
which  previously to  the  operation  pro-
duced  no good effect, to act, subsequently,
most powerfully and beneficially.  From
these  circumstances, therefore, a  resort to
paracentesis becomes,  in many instances,
of importance.  (See Paracentesis.)
   By most  practitioners, the operation is
strongly reprobated in ascites complicated
with pregnancy; occasionally, however,
to prevent  the imminent danger  of suffo-
cation with which  the patient is threat-
ened,  it becomes necessary to resort to it
in such cases.   Scarpa notices  the fact
and recommends that the trochar  be intro-
duced  between the edge of the left rectus
muscle and the  margin  of the ribs,  to
avoid injury to the uterus.  (Sulla Gravi-
danza sussiguita de ascite. 1827.)   That
the operation may be performed with per-
fect safety,  notwithstanding the accompa-
nying  pregnancy, we have abundant evi-
dence. Langstaff and Russel both cite
cases which show this very fully. (Quar-
terly Journal Med. Sciences.   Jan. 1824.
Lond.  Med. and Phys. Journ. May, 1827.)
   The diet proper for  a patient labouring
under  ascites, will vary somewhat accord-
ing to the circumstances of each  case.  It
should invariably, however, be light easy
of digestion, and unirritating; and in the
acute variety of the disease it should be
almost exclusively confined to decoctions
of the farinaceous  seeds, fresh whey, or
toast-water. Care must be taken through-
out the disease  to  guard the patient from
exposure  to damp and cold, as well as
from  all  sudden transitions of  tempera-
ture.
  Bibliography.—Sexnertus. De Hydrops as-
cite.  Wittemberg, 1616.
  Meibomius.  De Hydrope ascite.  Helmstadt,
1695.
  Stahl, (J. E.)  De  Hydrope, pracipui ascite.
Halle, 1701.
  Hoffman, (F.)  De Hydrope ascite.  Halle,
1718.
  Buchner.  De Hydrope ascite. Erford, 1743
  Vogel. Diss, hydropis ascitis semiologia. Got-
tingen, 1764.
  Roeder.  De paracentesi abdominis evacuanti-
bus internis in  ascite anteferenda et  de eandem
recti instituendi methodo.  Erford, 1799.
  Titius. De Hydrope ascite. Wittemberg, 1800.
  Fitzpatrick.  De  ascite  abdominali  Edin-
burgh, 1801.
  Lassis.  Sur les avantages de la paractnlese
practiquie dans le commencement de Vhydropisie
abdominale.  Paris, 1803.
  Villette.   Sur Vascite.  Paris, 1814.
  Clary-Bous(«jet. Sur Vhydropisie ascite avec
asthinie.  Montpellier, 1819.
  Lefevre.  Sur Vhydropisie ascite. Paris, 1820.
  Duges, (A.) Suntne inter ascidem et pcriloni-
tidem chronicam certa discriminaquibusdiagnosci
queant?  Paris, 1824.
  Barres. Considirations ginirales sur le traite-
ment de Vhydropisie ascite.  Paris, 1825.
  Ollivier.  Remarques sur Vopiration de la
paracentese dans Vhydropisie ascite compliquant
la grossesse; in Archives Gen. de Med. VI. 178.
  Chauffard.  Observations sur les bans effets
du traitement antiphlogistique dans Vascite febrile.
Journ. Gen. de Med. XCIV. 164-185.
  Scarpa.  Sulla Gravidanza  sussiguita de as-
cite.  Freviso, 1817.
  Elkinton.  Remarkable  case of ascites in  a
child.  American Journal of the Med. Sciences.
May, 1835.
  Dalmas.  Art. Ascite, in Diet, de Med.
  Bouillaud.  Art. Ascite, in Diet, de Med. et
de Chirurg. Prat
                         D. F. Condie.

   ASCLEPIAS. (Botany and Mat. Med.)
   Sex. Syst.  Pentandria digynia.   Nat.
Ord.  Asclepiadeae.
   Gen. Ch.   Cal. small, five-parted.  Ca-
rol, five-parted, reflexed.  Nect.  five-leav-
ed;  leaflets opposite the  anthers,  each
producing from its base, a subulate everted
process. Stigma five-angled, opening lon-
gitudinally, depressed.   Pollinia in  five
distinct pairs.  Follicles two-ventricose,
smooth or muricate. Seeds cornose.  Beck.
   This genus,  which gives its name to a
natural order, includes a variety of spe-
cies  differing  greatly in  their  physical
qualities.   Thus,  although  the   roots of
most  of them are  acrid and stimulating, 
ASCLEPIAS.
461
in  some species they are inert or nearly
so.  The milky juice with which they
abound is also, in most  instances, bitter
and poisonous, though in a few of them it
is  sweet and used as an  aliment.  Many
of them have at different times been  em-
ployed in medicine, though none of them
have been generally  recognized as legiti-
mate articles of the materia medica. Two
only require particular notice—the A. tu-
berosa, a native of the United States, and
the A. (Calotropis) Mudarii, peculiar to
India.
   It is true that several others of our na-
tive species have been experimented upon,
and have attained some celebrity;   but
this has been temporary and local, and un-
supported  by that decided testimony  in
their favour, which should always attend
the introduction of new articles into  the
materia medica.
   As, however, the A. Syriaca and A. in-
carnata have been admitted into the  sec-
ondary list  of the U.  S. Pharmacopoeia, it
becomes necessary to say a few words re-
specting them.  They are both stated to
be endowed with expectorant, diaphoretic,
and diuretic properties, and to have been
successfully  employed in asthmatic, ca-
tarrhal, and rheumatic  affections.    Dr.
Abijah Richardson, of Medway, in Mas-
sachusetts,  employed the A.  Syriaca, to
the amount of a drachm a day,  in divided
doses,  in cases of the above-mentioned
character, with the happiest  results.   In
all instances, it appeared to  exercise an
anodyne  effect,  relieving pain  and in-
ducing sleep. (Coxe. Am. Dispen.)   Dr.
Tully, whose experience with our native
remedies has been very great states that
the root  of the A. incarnata may be ad-
vantageously administered in catarrh, asth-
ma, rheumatism,  syphilis, and verminous
affections. The dose  is from half a drachm
to a drachm. (Bigelow.  Treat,  on Mat.
Med.)
   Many of the East Indian species have
also been resorted to  medicinally, as eme-
tics, sudorifics,  and antispasmodics, parti-
cularly the A. vomitoria,  A. volubilis, and
A. prolifera. (Ainslie. Mat. Ind.)
   A. tuberosa.   Butterfly Weed.   Pleu-
risy Root
   Sp. Ch. Stem erect, hairy, with spread-
ing branches;  leaves oblong-lanceolate,
sessile, alternate, somewhat crowded ; um-
bels numerous,  forming terminal corymbs.
Beck.
   This species  is found in all parts of the
United States, but is  most abundant in the
southern states.  It  presents many  vari-
eties, one of which, the decumbens, having
                  39*
a decumbent  stem,  and  almost  linear
leaves,  was  erected  into  a species  by
Linnjeus.   The part used in medicine is
the root: this  is large, formed of irregu-
lar tubers, but sometimes almost fusiform;
externally  of  a yellowish-brown colour,
internally white.   When  recent it pos-
sesses  a somewhat acrid,  and nauseous
taste.  In the dried state,  it is bitter,  but
loses its unpleasant flavour.  It is readily
pulverized, affording  a dirty-white pow-
der.   It imparts its properties to boiling
water.
  This root is diaphoretic  and  expecto-
rant  acting, however, without sensibly
augmenting the heat of the surface or ac-
celerating the circulation. In large doses,
especially if it be  recent,  it is cathartic.
It has long been a popular remedy in a
variety of affections,  and has been also
employed by many regular  practitioners,
with great success, in diseases of the re-
spiratory organs.   There  is the amplest
testimony  of  its  powers  in these  com-
plaints, when  administered judiciously.
Dr. Chapman states that it is distinguished
by great  certainty and permanency of
operation, and is well suited to excite per-
spiration in the forming states  of most of
the inflammatory diseases of winter; and
is not less useful, in the same  cases, at  a
more advanced period, after the reduction
of action by antiphlogistic remedies. (Ele-
ments of Therapeutics. I. 351.)
  It has  also  been advantageously em-
ployed  in acute rheumatism,  and  in  the
low  states of typhus fever, when  other
diaphoretics were  inefficient or even con-
tra-indicated.   Some  testimony  has also
been adduced of its powers in bowel af-
fections.  Dr. Eberle found it highly use-
ful in  dysentery  (Pract. Med.  I.  216.),
and  Dr. Parker,  of  Massachusetts, who
employed  it for  twenty-five  years,  had
the  greatest  confidence  in its powers.
(Bigelow. Med. Bot.  II. 26.)  It  is also
said  to be gently tonic, and has been popu-
larly employed in indigestion accompanied
with flatulence and pain,  whence one of
its common names, wind-root.
   A. (Calotropis) mudarii.  Mudar.  Ma-
dar.
   Sp. Ch.  Stem  erect,  smooth;  leaves
opposite,  nearly  sessile,  acute,  entire,
somewhat cordate at base;  calyx  very
small; corolla campanulate. Buchanan.
   The mudar or madar as it is termed by
Robinson, Ainslie, and Wallich,  is the
root of the A. mudarii, the Seifide of the
Hindoo physicians, and not of the A. gi-
gantea, as is generally asserted.   It ap-
pears, however, that the roots ofa number 
462
ASCLEPIAS.—ASPARAGUS.
of the asclepiadeoe are known under this
name in India, and that they all possess
analogous and almost identical properties.
(Cassanova. Essai sur le Madar.)  The
part used in medicine is  the  root.  This
is perennial, fusiform, branched, of a pale
fawn colour externally, wrinkled longitu-
dinally, and covered with a brownish pow-
der which soils the fingers.   Internally it
is whitish;  has little or no smell, but a
bitter  and  slightly nauseous  taste.   To
prepare the mudar, the  roots are dug up
in April and May, well washed and dried
in the open air, till the milky juice with
which  they abound  has become inspis-
sated ; the epidermis is  then scraped off,
and  the cortical portion removed for use;
this, when well dried, should be kept in
close bottles, as it is apt to attract mois-
ture.   The  powder is of a pale fawn  co-
lour.  (Duncan.   Edinb. Med. and Surg.
Journ.  XXXII. 62.)  From an analysis
made by Cassanova, it appears to contain,
1. an extractive substance (Madarine) so-
luble in alcohol and water, and which is
probably its active principle, 5.00: 2. a
resin remarkable  for its property  of net.
melting at 212° F., and its slight solubility
in alcohol, 4.00:  3. a gum, probably con-
taining some madarine, 3.00:  4.  a large
quantity of starch:  5.  albumine:  6. a
little  fixed  oil:  7. lignin.  This agrees
with the analysis by Duncan, except that
the latter found  a greater  proportion  of
madarine, 11.5.
   The remedial properties of this article
are undoubtedly of a high order, and the
concurrent testimony of a number of emi-
nent practitioners shows  that it has been
eminently successful in the obstinate cu-
taneous affections so common in tropical
climates.   Robinson speaks of it in the
most exalted terms, in elephantiasis and
lepra (Med. Chirurg. Trans. X. 31.), and
Playfair states  that he has found it of
the greatest service in lepra, hectic fever,
rheumatism, &c. (Trans. Med. and Phys.
Soc. Calcutta.  I. 77.)   He  gave  it in
doses of grs. iii. to xii., three times a day,
gradually increasing  the  quantity.  Cas-
sanova, who experimented largely with
it, confirms these  statements.  He says
that its action is more particularly direct-
ed to the skin, increasing the  action of
the capillaries and absorbents of that tis-
sue.   When combined with opium, it acts
as a diaphoretic, and in small doses is ex-
pectorant  and tonic.  In large doses it
causes  nausea  and vomiting.   Duncan,
who made many trials with it in the Royal
Infirmary  at Edinburgh, states that he has
satisfied himself that  in every  respect its
action is so similar to that of ipecacuanha,
that this might be dispensed with.   He
was unsuccessful with it in elephantiasis,
but found it highly beneficial in psoriasis
and lepra.
   Dr. A. T. Thomson is of opinion  that
in many respects it resembles mercury in
its operation on the system, and has proved
most beneficial in low states of the habit,
indicated by pallidness, emaciation, disor-
dered digestion, &c.: in an opposite  con-
dition, it proves decidedly injurious. Dur-
ing its  use he also states that the diet
should be mild and vegetable.  (Elements
Mat. Med. II. 492.)
   Ainslie, from his own observations  in
India, prefers the dried milky juice to the
root;  and  if the principle described by
Duncan  and Cassanova be the active in-
gredient it is most probable that this juice
contains a larger proportion than the dried
root (Mat. Ind. II. 486.)  Duncan, how-
ever,  is disposed to think this opinion ill
founded, grounded on an analysis of the
milk of  the A. Syriaca  by Dr. John, of
Berlin, showing that it contained a large
proportion  of inactive resin.
  The A. gigantea, which, as has already
been stated, has generally been assumed as
the plant furnishing the Mudar, is likewise
employed in India,  and  apparently with
equal success. It has also been naturalized
in the West Indies, where it  has been
prescribed  in the same  class of diseases,
especially in the French islands, with the
happiest results.  It is noticed by Browne
as very  common in Jamaica, where it  is
known by the name of French Jasmin.  It
is used  in powder,  in doses of gr. x.  to
3i., in which doses it proves emetic.  The
infusion made by pouring gviii. of  boiling
water on 3iii.  of the powdered root, also
excites emesis in doses of fjii. to 3iv. In
smaller  quantities,  both  preparations act
as alteratives and expectorants.
   From  all that can be gathered on the
subject  of madar, it appears evident  that
it is  closely allied  in its  effects  to the
Apocynum androsemifolium (q. v.), which
contains, according  to the experiments of
Drs. Knapp and Griscom,  an active prin-
ciple, analogous if not identical with the
Madarine.            R. E. Griffith.
   ASPARAGUS. (Bot.  and Mat.  Med.)
  Sex. Syst. Hexandria Monogynia.  Nat.
Ord.  Asphodeleffi.
  Gen. Ch.   Corolla six-parted,  erect;
three  inner petals  reflexed at  the apex.
Berry three-celled,  two-seeded. Willd.
   A. officinalis.— Asparagus.—Asperge-
Fr.;  Spargel, Germ.—Sp. Ch.   " Stem
herbaceous, unarmed, round, erect; leaves 
ASPARAGUS.
463
setaceous,  usually  fasciculate;  stipules
sub-solitary."   This  plant  is  too  well
known to require description.  It is a na-
tive of Europe, but has been  naturalized
in some parts of the United States, and is
everywhere cultivated for  table  use.  By
the ancients it was employed both as a cu-
linary vegetable, and as a medicine.   All
parts  of the plant  are  probably  possessed
of the same virtues ; but the  roots, young
shoots, and berries, are the only portions
used.
   The root consists of a thick, short body,
and numerous radicles, about as large as
a quill, which proceed from the under sur-
face.  In the recent state, it is whitish and
succulent; when  dried, it is gray, soft,
and spongy, without odour, and  of a fee-
ble, sweetish, slightly bitter taste.  Du-
long  found in  it  a bitter extractive  mat-
ter, a saccharine substance, albumen, gum,
an odorous resin, and salts.  The shoots,
before being boiled,  have  a disagreeable
 bitterish taste.  Their juice was found by
 Robiquet and Vauquelin to contain, be-
 sides  albumen, mannite, &c., a peculiar
 principle, to which the name of asparagin
 has been given,  and  which  has subse-
 quently been  discovered in other plants.
 It is  a crystallizable substance, without
 smell, of a feeble  nauseous taste, soluble
 in water and diluted alcohol, but insoluble
 in absolute alcohol and ether.   Its ulti-
 mate constituents are  oxygen, hydrogen,
 carbon, and nitrogen.  It  is  neither acid
 nor alkaline,  but, when boiled in water
 under pressure, or in an alkaline solution
 without pressure, is converted into a salt
 consisting of ammonia and a peculiar acid
 called aspartic (q. v.).   A  new nomencla-
 ture has recently been proposed for proxi-
 mate vegetable principles possessing these
 properties, in conformity with which, as-
 paragin is called asparamid,  and the acid
 resulting  from its decomposition,  aspar-
 mic acid.   The berries have a disagree-
 able,  sweetish, somewhat acrid  taste, and
 are susceptible of the vinous fermentation.
   Effects on the system, Therapeutic use,
 Slc.  The root of asparagus was employed
 as a medicine by the ancients, and is still
 occasionally used, though  seldom in this
 country.  It exerts little sensible influence
 upon the  system; but communicates a pe-
 culiar odour to the  urine, and  is thought
 to be diuretic. It is prescribed in dropsi-
 cal complaints, as an  adjuvant to more
 powerful  medicines.  The form of decoc-
 tion  is usually preferred.   From half an
 ounce to an ounce of  the  root is boiled in
 a pint of water,  and the decoction em-
 ployed as a drink, ad libitum.   The root
of asparagus is one  of the species diure-
tica, and a .constituent of the  syrupus e
quinque radicibus of the  Paris  Codex,
and enters into various other combinations
directed by different European Pharmaco-
poeias.  It  is  said that  the roots of the
wild plant are preferable to those of the
cultivated.
   The  shoots, when boiled, constitute a
pleasant and  wholesome aliment, pecu-
liarly useful in consequence of its occur-
ring early in spring, when few other fresh
vegetables  are  attainable.   They  have
been long known to impart a peculiar dis-
agreeable odour to the urine.  It has been
a  question  whether they  produce  this
change in the urine  merely by affording a
new constituent to the blood to be  elim-
inated  by the kidneys,  or  whether they
excite  the kidneys  themselves to an in-
creased and altered action.  The  experi-
ments of M. Gendrin seem to leave no
room for doubt that they are actively diu-
retic.   He  gave a  syrup prepared from
the shoots,  to numerous individuals, and
found that,  in every  instance, the  urine
was  increased  in  quantity.  When  the
syrup was taken in the dose of two ounces,
the urine was equal to  three times, four
times, or even five times the  amount of
drink employed.  At the same time, thirst
was experienced by the greater  number
of persons  subjected to experiment,  and
an increased appetite by all. The  diuresis
ceased on  the day succeeding  that in
which the syrup was used.  In no instance
did M. Gendrin observe the odour of as-
paragus in the urine.  (Gaz. Med. de  Pa-
ris. June, 1833.)
   It  was formerly  supposed that aspara-
gus, when very freely taken as an article
of diet, was capable of provoking into ac-
tion various complaints to which a predis-
position might exist.  Attacks of hemop-
tysis, gout piles, menorrhagia, and bloody
 urine, have been ascribed by different au-
 thors to this cause.  But  the probability
 is, that if  these effects were really  pro-
 duced  by  the  asparagus,  they  resulted
 rather from the immoderate quantity than
 from  any  peculiar  quality  of  the  food
 taken.  So far, indeed, from possessing
 any  general  excitant property, asparagus
 is by some  authors considered as  sedative
 in its  influence over the  heart,  and has
 been highly  recommended in complaints
 of this organ, and in others attended with
 an irritated state of the circulation. Broi>-
 sais speaks  very favourably of it  in hy-
 pertrophy  of the  heart  unaccompanied
 with phlogosis of the stomach. (Ann. de la
 Med. Physiolog. XVI. 12.)   By some, it 
464
ASPARAGUS.—ASPARTIC.
is  regarded as a general sedative, and is
asserted to have been useful not only in
neuralgic affections, but in painful organic
complaints, obstinate coughs, and nervous
excitement from various causes. It is even
said to obviate the effects of coffee, and to
prevent the wakefulness  which so  com-
monly results from the use of this stimu-
lant.  Cases are recorded by M. Cassaign-
ard, in which violent palpitations of the
heart, attended with other unpleasant pec-
toral symptoms, were relieved  or  cured
by this remedy. (Journ. de Pharm. XIX.
672.)   It is, however, denied by Gendrin
that asparagus has any immediate action
on the heart.   In the numerous cases in
which he employed  it, he never found the
pulse diminished by its use a single stroke.
The relief of dyspnoea which it sometimes
occasions in cardiac  affections, he ascribes
to its diuretic operation.   A diet  of aspa-
ragus has been recommended in chronic
cases to which the remedy is applicable;
but  the regulated employment of  some
preparation in which the  inert or merely
nutritive portion has been got rid of,  is de-
cidedly preferable;  especially as, in boil-
ing the shoots, much  of their active prin-
ciple must  be extracted  by the water.
The preparation of the shoots usually em-
ployed  is the syrup.  The following is the
formula most  in use.  Take  a  sufficient
quantity of fresh asparagus, bruise  it in a
mortar of stone or wood, express the juice,
heat this by means of a water bath till the
albumen is coagulated; then filter,  and to
each pound of the juice add thirty ounces
of refined  sugar;  lastly,  strain through
flannel. (Diet, de Med, IV. 213.)  Bufthe
syrup prepared  in  this manner is  apt to
undergo fermentation, and to become de-
teriorated by  time.   In order to  obviate
this result, M. Latour proposes  that  the
 juice filtered after the coagulation  of the
albumen should be mixed with an  equal
weight of powdered sugar, and the mix-
ture carefully dried by artificial heat. The
inspissated juice thus  prepared may  be
kept in well-stopped  vessels, and  when
wanted for use may be made into a syrup
by adding half its weight of water, heat-
ing to  the boiling-point,  and  straining.
The same author also proposes to treat the
parenchyma  remaining after the  expres-
sion  of juice, with alcohol,  to  evaporate
 the resulting tincture sufficiently, then to
 add sugar and evaporate to dryness.  The
 extract thus obtained may be mixed with
 the inspissated juice in the preparation of
 the syrup. For the particulars of the  pro-
 cess, the reader is referred to the Journal
of the Philadelphia College of Pharmacy,
VI. 122.
  The syrup  of asparagus may be given
in the quantity of from half an ounce to
three ounces daily.  A syrup may be pre-
pared also from the unripe berries, which,
from  its sensible properties,  is  probably
capable of producing  on the  system the
same effects as that made from the shoots.
The author of this paper has employed
such a syrup in a case of diseased heart,
with  apparent  advantage.   An extract
from the berries has also been proposed.
  It is stated that another species of as-
paragus,  the  A. acutifolius,  has all the
properties of the A. officinalis.
                       Geo. B. Wood.
  Bibliography.—Baier.  Diss, de aspara'go.
4to.  Altorf, 1715.
  Frantz.  Diss, de asparago ex scriptis medi-
corum veterum.  4to.  Leipsic, 1778.
  Ratier. Art. Asperse, in Diet de Med. et de
Chirurg. Prat.   III. 540.  Paris, 1829.
  Br.oussais.  Therapeutique sur les moyens >:'■
datifs de la circulation et sur lespointes d'asperge;
in Annales de la Med. Phys. XVI.  Paris, 1829.
  Merat and De Lens.  Arts. Asparagine, As-
paragus, and Asperge; in Diet de Mat. Med. 1.
469-471.  Paris, 1829.
  Richard and Soubeiran.  Art. Asperse, in
Diet, de Med.   IV. 211.  Paris, 1833.
  Gendrin.  Remarques sur les effets Utirapeu-
tiques du  sirop et de Vextrait de pointes a'as-
perges; in Gaz. Med. de Paris. I.  429. (15 June,
1833.)—Ibid. Note sur faction diuretique des pre-
parations dAsperge; in  same Journal. I. 809.
(30 Nov. 1833.)
  Boutros-Charlard and Pelouze. Mimoire
sur VAsparamide (Asparagine de M. Robiquet);
in Journ. de Pharm.  XIX. 208.  Paris, 1833.
  Rodiquet and Dumas.  Rapport sur cette Mi-
moire, in same Journal.   XIX. 243.
  Gourdan.   Palpitations; emptoi du sirop de
pointes d'asperges en lavement [guerison]; in Lan-
cette Francaise.  VII. 441.  Paris, 1833.
  Emery. Emploi du syrop de pointes d'asperges
dans les affections du cceur, in same Journal. VII.
433.
  Regimbeau.   Mimoire sur Vasparagine, in
Joum. de Pharm.  XX. 631.  Paris, 1834.
  Johnson. Mcmoire sur le sirop de pointes oVas-
perges.  8vo.  Paris, 1834.
  Fuzet-Dupouget.   Obs. sur la propriiti du
sirop de pointes d'asperges; in Gaz. Med. de Pa-
ris.  III. 158.   (1835.)
                                 I.  H.

   ASPARTIC  or ASPARMIC  ACID.
An artificial acid,  discovered by Henry
and Plisson, and  produced by the action
of certain substances on asparagin, now
 called asparamid, as a member ofa group
of azotized substances denominated amids,
 which are characterized by being con-
 verted by strong acids or bases, into am-
 monia and various acids.  In the case of
 asparamid, the characteristic  change pro-
 duced by the  agents  indicated,  is into 
ASPHYXIA.
465
 ammonia  and a  peculiar acid called as-
 partic.
   Aspartic acid is best obtained by acting
 on asparamid in powder with the oxide of
 lead, diffused in water at the boiling tem-
 perature,  as long as  ammonia  is disen-
 gaged.  Aspartate of the oxide of lead is
 formed, which  is  then to be decomposed
 by means of a current of sulphuretted hy-
 drogen, for the purpose of throwing down
 the lead, and liberating the aspartic acid.
 The liquor is then evaporated  to dryness,
 and the dry mass,  treated with boiling
 commercial alcohol  which takes up  the
 acid, and  deposites it again on cooling in
 the  form  of minute  scales.
   Properties.   This  acid  possesses  no
 odour, and only a slight acidulous taste.
 It is soluble in 128 parts  of cold  water, is
 more soluble in boiling water, less so in
 diluted alcohol, and  is insoluble in abso-
 lute alcohol.  Muriatic  acid dissolves it
 more copiously than  water, sulphuric acid
 decomposes it, and  nitric acid is without
 action on it even at the temperature of
 ebullition.  It consists, according to Lie-
 big, of five equivalents of hydrogen, eight
 of carbon, one of nitrogen, and  six of oxy-
 gen, a composition which corresponds with
 that of asparamid, minus the constituents
 of ammonia.
   Aspartic acid neutralizes bases, forming
 aspartates,  several  of which  have been
 examined.  The neutral aspartates of po-
 tassa,  soda, ammonia, baryta,  lime,  and
 magnesia are soluble in water.  That of
 potassa is deliquescent. The aspartate of
 ammonia, although agreeing precisely in
 composition (isomeric) with asparamid, is
 nevertheless not  identical  with  it.  The
 aspartates of lead, protoxide of mercury,
 and silver are either  insoluble or sparingly
 soluble.   The  insoluble  aspartates   are
 formed  by double decomposition, and  the
 soluble ones, by decomposing the aspartate
 of baryta  by the  sulphate of  the given
 base.  The  barytic  salt is prepared by
 treating  asparamid  with barytic  water,
 and removing the excess of base by means
 of sulphuric acid.
   Aspartic acid has no uses.
              \J   Franklin Bache.
   ASPHYXIA/ (From a priv.  and o$v%i$,
 pulse.) This term, in its original accepta-
 tion, means "want  of pulse."   In  this
 sense, it was used by Galen and the older
 writers, and  is still occasionally employed
 by the moderns.   It is not  many years
 since  Mr. Chevalier  (Medico-Chirurg.
 Trans. I.  157.) described some suddenly
fatal  cases of heart  affection,  under the
name  Asphyxia idiopathic a,  and we find
the term, even at the present day, extend-
ed so as to include every variety of sus-
pended  animation; but,  in its  usual  ac-
ceptation with the best writers, like  ap-
nosphyxia, it is restricted to cases of ap-
parent death, which result primarily, and
principally from the suspension of respira-
tion ;  whilst syncope  is commonly applied
to death commencing in the heart, and
apoplexy to the variety which is primarily
dependent upon a suspension of the action
of the brain.  Of late, too, the epithet  As-
phyxia has been applied to the  condition
of malignant  cholera, marked  by pulse-
lessness and  other symptoms  of collapse,
—an  extension of application, which  the
term would scarcely seem to admit of, al-
though many of the phenomena are pre-
sent,  which  characterize  asphyxia from
suspension of the  respiratory function.
  § 1. Asphyxia in general.  Asphyxia,
in the sense  in which we employ  the
term, may be produced by any agency
that interferes with the due  aeration of
the blood.  No truth  is better established
in physiology, than that no organ  of the
animal  frame can properly execute its
functions, unless it receives a due  supply
of blood, which  has been exposed  to  the
contact of air in the  lungs, or  in some
other organ of the body.  Without such
supply, the capillary functions fail; secre-
tion, nutrition, and calorification, are no
longer duly  effected;  asphyxia or  sus-
pended animation  results;  and  this state
becomes converted into positive death,  un-
less steps are taken to effect the conver-
sion of the venous into arterial  blood, be-
fore  the circulation is irrecoverably  ar-
rested.
  Of the necessity of a due supply of ar-
terial blood, no one now doubts,—but its
absence has not always been regarded as
the main cause  of asphyxia;  on the con-
trary, the common belief has been,  that
the presence of unconverted, or in other
words, of black or  venous blood in the  tis-
sues is positively deleterious, and that as-
phyxia is caused rather by its presence in
the vessels, than by the absence of blood
possessing arterial  qualities.
  Assuming, for the present, that the for-
mer  of the opinions is the more correct,
it will be obvious, that mechanical or other
impediments, which interfere with the  ne-
cessary contact between the blood in  the
pulmonary vessels and atmospheric air,
or air necessary for producing the conver-
sion  of venous into arterial blood in these
organs, will be the cause of asphyxia.
  Accordingly, any agency, which pre-
vents the due  expansion of the  chest, by 
466
ASPHYXIA.
pressing upon its parietes,—as in the pun-
ishment occasionally  inflicted  by  the
Turks on their prisoners, which consists
in burying them up to the  neck in earth
or sand, and pressing the earth firmly
around  them,—or,  as in that which has
been  directed  by  the tribunals of more
civilized countries, by placing weights on
the chests of the wilfully mute,—will pre-
vent  the due quantity of air from enter-
ing the lungs,  and induce  a most painful
form  of asphyxia.    In  the latter case,
breathing might,  for a time, be accom-
plished by the diaphragm; but in the for-
mer,  even  this imperfect  respiration is
prevented  by  the  firm  pressure  of the
earth on the abdominal parietes, which
necessarily  prevents  any descent of the
diaphragm.
  It  is obvious,  too,  that  any  disease,
which mechanically  interferes  with  the
due  elevation  of the  ribs,  must  produce
more or less of this effect;  as where wa-
ter, or air or other fluid is effused into the
cavity of the thorax,  constituting  the  af-
fections respectively known by the names
hydrothorax, pneumothorax, and pyotho-
rax;  or where the lining membrane  of
the chest—the pleura—is  inflamed,  so
that elevation  of the ribs, or any attempt
at elevation, excites intense pain.  In the
last case, however, the obstructed aeration
is not as strongly manifested, owing to
respiration being still carried on, although
imperfectly, by the diaphragm.
  Another cause of asphyxia is the insuf-
ficient supply,  or total absence, of oxygen
in the  inspired air.   Hence, extremely
rarefied air,  and various gases, which are
not of  themselves  positively deleterious,
may become negatively so.  Unless  the
air contains a due quantity of oxygen, and
that properly  diluted by  nitrogen,  the
change of the  venous blood into arterial
cannot  be  effected.  In atmospheric air
alone we find the admixture  of these
gases in the requisite proportion.   Unless
this air be supplied in proper quantity, the
beneficial conversion cannot be sufficiently
effected, and asphyxia may equally ensue.
  The negatively injurious gases are,—
hydrogen  and  azote,  to which carbonic
acid has been added by some (Roget. Art.
Asphyxia, in Cyclopadia of Pract. Med.
I. 167.), but its lethiferous  influence is
exerted in  a somewhat different manner.
The hydrogen  and azote are capable  of
being respired for  a short time, and they
destroy, simply because they do not con-
tain oxygen; but carbonic acid, as well as
various  other  gases,  in a  concentrated
state, cannot be breathed at all, producing,
the very instant any attempt is made to
inhale them, a spasmodic closure of the
glottis.  They belong, therefore, to a third
set of causes;, comprising those that pro-
duce  asphyxia in consequence of their
forming media that are incapable of being
inhaled.
  The  irrespirable gases  are, carbonic
acid,  ammoniacal gas, muriatic acid gas,
deutoxide of azote, nitrous acid gas, and
chlorine.  Different writers have  classed
under the  same  head,  oxygen, carbonic
oxide, protoxide of azote, carburetted hy-
drogen,  sulphuretted  hydrogen,  and ar-
senuretted hydrogen; but these gases give
rise to no symptoms resembling asphyxia.
They are positively deleterious, and the
only difference  between  their action  and
that  of  other poisons is, the part of the
economy through which  they make their
impression.  Their consideration, there-
fore, properly falls under the head  of Poi-
sons.  They are capable of being breathed:
they produce a train of morbid phenome-
na, which,  in  the case of some  of the
gases, rapidly  succeeds, even  if the gas
be only allowed to come in contact with
the skin, and they are no more the cause
of asphyxia, than would be the vapours of
arsenic, or of the deadly hydrocyanic acid,
if inhaled.
  A last set of causes are those, which
mechanically prevent the entrance of air
into the pulmonary organs, whether such
obstacle be seated externally or internally.
To this  set  belong—hanging; strangula-
tion, and every variety of smothering; ob-
struction of the air  passages  by  the  en-
trance of extraneous  bodies,  by the pres-
sure of tumours, or by any morbid thick-
ening of the lining membrane of the tubes.
Any disease, too, which gives occasion to
the effusion of blood  or  other fluids into
the minute bronchial ramifications, and
thus prevents  the air from  exerting  its
necessary action on  the blood, produces
death in this manner.  Direct or indirect
irritation, or paralysis of the pneumogas-
tric nerves, causes asphyxia,  and death,
partly in this way, and  partly by  impair-
ing the powers of the respiratory muscles.
It has been long an  interesting topic  of
inquiry to discover the effect of depriving
the respiratory  organs  of their  nervous
supply from the  encephalon.   The  only
encephalic nerves they  receive  are  the
pneumogastric  or eighth pair  of Willis,
which,  as their  first name imports,  are
distributed to both the lungs and  the  sto-
mach. The division of these nerves early
suggested itself to physiologists, but it is
only in  comparatively recent times, that 
ASPHYXIA.
467
the phenomena, resulting from such divi-
sion,  have  been accurately  appreciated.
The  operation seems to have been prac-
tised as far back as the time of Rufus the
Ephesian, and was afterwards repeated by
Chirac,  Bohn, Duverney,  Vieussens,
Schraeder, Valsalva, Morgagni, Hal-
ler,  and many other eminent investiga-
tors of the animal economy. It is chiefly,
however, in very recent times, and mainly
by the labours of Dupuytren, Dumas, De
Blainville, Provencal, Legallois, Ma-
gendie, Breschet, Hastings, Broughton,
Brodie, and Wilson Philip, that the pre-
cise effects upon the respiratory and diges-
tive functions have been determined.
  When the pneumogastric nerves are
divided  in a living animal, on both sides
at once, the animal dies  more  or less
promptly,—at  times, immediately  after
their division; but sometimes it lives for
a few days; Magendie says, never beyond
three or four: but this differs  in different
animals, and does not apply universally to
the same animal. A dog, in which M. Se-
dillot divided  the  nerves of both  sides,
lived upwards of two months.  (Berard.
Art. Asphyxie, in Diet, de Med. 2de edit)
As regards the larynx, precisely the same
effects are produced by dividing the  trunk
of the pneumogastric nerve, above where
it gives  off the  recurrents that proceed to
the larynx,  as by the division of the re-
currents  themselves: the muscles, whose
function  it is to dilate the  glottis, are pa-
ralyzed ;  and consequently, during inspira-
tion, no  dilatation takes place; whilst the
constrictors  of the glottis,  which receive
their nerves from the superior laryngeal,
—branches  given off from the  pneumo-
gastric above the point of section,—pre-
serve their action, and close the glottis, at
times so completely, that the animal dies
immediately from suffocation.  But  if the
division  of these nerves should not induce
instant death in this  manner, a series  of
symptoms succeeds,  considerably alike in
all cases, which persist until  the animal
dies. These phenomena are as follows:—
the respiration is at first difficult; the in-
spiratory movements are more extensive
and rapid; the locomotive movements less
frequent, and they evidently give fatigue.
Frequently,  the animal remains  entirely
at rest:  the  formation  of arterial blood is
not prevented at first:  but soon,—on  the
second  day, for example,—the  difficulty
of breathing augments, and  the inspira-
tory efforts become gradually greater. The
arterial blood has now no longer the ver-
milion hue which  is proper  to  it  It is
darker than  it ought to be.  Its tempera-
ture falls.  Respiration requires the exer-
tion of all the respiratory powers.   At
length, the arterial blood scarcely differs
from the venous, and the arteries  contain
but  little  of it; the  body gradually be-
comes cold,  and  the  animal  dies.  On
opening  the  chest, the bronchi, in their
minutest ramifications, and frequently the
larger tubes,  even the trachea,  are found
filled by a frothy fluid, which is some-
times bloody; the substance of the lung
is engorged; the divisions, and even the
trunk of the pulmonary artery, are greatly
distended with dark, almost black, blood;
and extensive effusions of serum, and even
of blood, are  found in the parenchyma of
the  lungs.   Experiments have likewise
shown, that,  in proportion as these symp-
toms supervene, the animal consumes less
and less oxygen, and gives off a progress-
ively diminishing amount of carbonic acid.
  From the  phenomena that follow  the
section of  these nerves on both sides, it
would seem, that the first effect is exerted
on the tissue of the lungs, which, being
deprived of the  nervous influence they re-
ceive from  the brain, are no longer capable
of exerting their  ordinary elasticity—or
muscularity—whichsoever it may be. Re-
spiration consequently becomes difficult:
the blood, owing to defective oxygenation,
no  longer  circulates  freely through  the
capillaries  of the lungs; the consequence
of this is,  that transudation of its more
watery portions takes place, and occasion-
ally effusion of blood, owing to rupture of
the small vessels, or to transudation through
their parietes; so that ultimately all com-
munication is prevented between  the in-
spired  air and the blood in the pulmonary
vessels.  The conversion of venous into
arterial blood  is  completely  prevented;
the animal becomes asphyxied, and death
is the inevitable consequence, because the
mischief done to the nerves by the sec-
tion, cannot be repaired. (Magendie. Pre-
cis de Physiol.   Edit. 2e. II. 355.)
  The phenomena following the division
of the pneumogastric  nerves  throw con-
siderable light  on a variety of asphyxia
produced by  morbid causes, to which at-
tention was  first  drawn by Dr. John
Clarke. (Commentaries on some of the
most important diseases of children. 1815.)
It consists  essentially  of a violent spasm
of the constrictor  muscles of  the  glottis,
which completely prevents the entrance
of air into  the lungs, and destroys in  the
same manner as if the individual were
placed in an irrespirable medium, or had
a ligature  put  around  the neck.  It has
been met with  in  the  adult (Kay on As- 
468                   ASPHYXIA.  (General phenomena.)
phyxia,  p. 79.), but generally occurs in
infants of very excitable temperament be-
ing  brought on  by fits  of  laughter, or
screaming, which call the respiratory sys-
tem of nerves into immediate and irregu-
lar action, so that the  glottis closes; the
laugh or the scream  is  instantaneously
arrested, and respiration  at  once ceases.
The erethism is  probably seated, in these
cases, in the superior laryngeal nerves, cr
in the part of the  encephalon whence they
originate;  although, as  experiments on
the division  of the pneumogastric nerves
show, paralysis of the recurrent nerves,
which are distributed to the  dilator mus-
cles  of the  larynx, by destroying the an-
tagonism between  the  dilator and con-
strictor  muscles,  may produce the same
result.
   1.   General phenomena of asphyxia.
These necessarily vary according as the
supply of  oxygen  is diminished or to-
tally  withheld;  and  according to  the
degree in which the supply is diminished.
There are some slight differences, also,
according to the precise  mode in which
the supply  is cut off;  but  still certain
symptoms and appearances are met with
in all.
   When the  access of oxygen  is in any
manner prevented, a few seconds elapse
before any uneasiness is experienced; but
after this, a marked feeling of distress in-
dicates the  necessity of satisfying one of
the most imperious wants—that of respir-
ing.   This feeling soon becomes insup-
portable ; the animal gasps, and yawns re-
peatedly, and makes use of every effort to
obtain a supply of the indispensable fluid.
The  whole body  is agitated.   The limbs
quiver; and are convulsed, or thrown into
tetanic spasms.   Almost instantaneously,
especially if respiration has been slightly
practicable, and  the supervention  of as-
phyxia therefore  gradual, the feeling of
distress  is  attended  by vertigo,  and  stu-
por :  the  face becomes livid, especially the
lips,  and  the orifices of the mucous mem-
branes;  and  at times the whole surface
assumes  the same  hue.  The  sensorial
functions are suspended in a few moments;
and,  almost simultaneously,  the  muscles
lose the power of contraction, so that the
individual falls.   In  this state of apparent
death, an obscure circulation  alone  exists
in the great vessels, whilst the functions
of the capillary system continue.  Soon,
however, the circulation ceases, first of all
in the larger vessels, and afterwards in
the capillaries; and, with this cessation,
the functions of secretion, nutrition, and
calorification, are arrested. The asphyxia
has now become positive death.
   Examination of the body after death
exhibits general  lividity  of  the  surface,
and of the face more especially.  The pa-
renchyma  of the different organs is filled
with  fluid,  especially  that of the liver,
spleen,  kidneys, and of the lungs.  Indeed,
the whole general capillary 6ysteni  is sur-
charged with blood of a dark colour, which
is described by some  writers  as always
fluid (Adelon.  Art. Asphyxie,  in Diet, de
Med.  1 edit. p. 68.); but to this there are
many exceptions. (Berard.  Loc. Cit. IV.
224.)  The blood appears to be wholly col-
lected in the pulmonary artery, the right
side of the heart,  and  the venous system
generally,  whilst  the  pulmonary  veins,
the left cavities of the heart, and the ar-
teries,  are  empty, or contain but a small
quantity of fluid.   The appearances, how-
ever,  differ somewhat, according as  the
respiration  is at once  obstructed, or  has
taken place, although  imperfectly, for a
time.   In the former case, death ensues
more promptly, and there is less suffering;
and, on examination, the  cutaneous capil-
laries  and   the various organs are less
charged with blood, and  the  fluid is less
exclusively  collected in  the  venous sys-
tem.
  The appearance of the  countenance has
been looked upon as a means of discrimi-
nation   in  death  from  asphyxia, where
there has been much previous struggling;
but it  is extremely fallacious.  The me-
chanical obstacles to the  return  of blood
from the head, in some forms of asphyxia,
and the convulsive efforts in all, give rise
to protrusion of the eye-balls, and to more
or less  distortion  of the  features, whilst
life exists;  but these signs usually disap-
pear,  so that when death has  unequivo-
cally  taken  possession of the  frame, no
indications of suffering may be percepti-
ble in the countenance.   A recent writer
(Copland. Art. Asphyxy, in Diet, of Pract.
Med.)  has remarked,  that where no ob-
stacle exists to the action of the inspira-
tory muscles,—the obstruction  to respira-
tion being in the air  passages,—the ef-
forts to  renew the air in the  lungs are
much more  convulsive and laborious; the
anxiety is extreme, but of short duration,
and is  rapidly followed  by  abolition  of
consciousness, voluntary  motion, and  of
the function of circulation.   In this case
he considers Shakspeare's description  of
the frightful physiognomy of Duke Hum-
phrey, after death from  suffocation, phy-
siologically accurate:— 
ASPHYXIA.  (General phenomena.)
469
" Bat see! his face is black and full of blood ;
 His eye-balls farther out than when he lived,
 Staring full ghastly like a strangled man :
 His hair uprear'd;  hi6 nostrils stretch'd with
    struggling :
 His hands abroad display'd, as one  that grasp'd
  And tugg'd for life, and was by strength sub-
    dued."
  Many  of these signs  may, or may not
exist and this will be  greatly dependent
upon the length of time the mechanical
violence  may have been applied.  If the
rope, for example, were removed prior to
the coagulation  of blood  in the vessels,
they might be entirely absent;  but if kept
on until  all circulation—general and ca-
pillary—had  ceased,   the  congestion  of
blood in the vessels, and the protrusion of
eye-balls,  might be present  as  in Duke
Humphrey's  case.   Usually,   however,
whatever distortion or mark of  suffering
may have existed prior to dissolution, there
is little or no evidence of it after the spirit
has passed, when the features usually ex-
hibit a placidity of expression—a " rapture
of repose" — singularly contrasting  with
their  previously excited condition.  (See
Art. Death, and the Author's Human Phy-
siology, 2d edit.  II. 556.)  The author has
had different opportunities for examining
the countenances of those who have been
judicially hanged,—where  the  rope has
consequently been removed prior to the
total abolition of the vital properties,—and
in none  of the cases were there the  evi-
dences of suffering,  in  the features, that
have been so often  described—by poets
more especially.
   There is another symptom of asphyxia
from  mechanical  obstruction  to respira-
tion, to which our  attention was first di-
rected by H.  H. Hayden, Esq.,  a scien-
tific and intelligent Dentist, of Baltimore;
namely—redness of the teeth,  which  can-
not be removed by maceration,  so as  to
have the whiteness  restored.   This  is
either owing  to the  cause mentioned by
Mr. Hayden,  in  the  following  extract
from  a  letter with which  he kindly fa-
voured us,  or  to the  flow of blood, in the
veins of the teeth, being arrested by the
cause producing the  asphyxia, so that en-
gorgement of the dental veins supervenes,
with consequent transudation.    The  phe-
nomenon  is, in any point of view,  sin-
gular :—
  "In certain varieties of asphyxia, the appear-
ances of the teeth are not only  singular, but
highly  instructive,  in a physiological  point  of
view, especially.  Thev are almost  uniformly
tinged red.  If examined  immediately after death,
they present a deep pink hue; if some time after,
the tint is darker. The different shades of colour,
  vol. n.           40
however, will generally depend, in a great mea-
sure, upon the age of the person, and the vio-
lence of the death:—for instance, the bony struc-
ture of the teeth of young persons is far more
transparent and vascular than those  of persona
advanced in years.  These appearances are par-
ticularly observable in the teeth of such as have
been drowned,  and  more  especially in those
that have been hanged.  They  are,  moreover,
met with in the teeth of refractory bullocks that
have been forcibly  drawn  into the  slaughter-
house, by means of a rope round the neck.   My
attention was attracted to these, and to many
other appearances of the teeth,  about the year
1815; since which time I have observed them in
numerous instances, both in human teeth and in
those of  the bullock.
  On examining the teeth for the purpose of as-
certaining, if possible, the nature and cause of
these appearances, I found, on splitting them
open through  the roots, or fangs (which ought to
be done from  the edge of the crown, so as not to
touch or disturb the vessels of the  tooth), the
whole  nervous  pulp turgid,  almost black,  and
even surrounded with blood.  From  this condi-
tion of the vessels, one might be led  to suppose,
that the red  tint of the teeth  was reflected
through the bone.  But on removing the nerves,
I found that the bony substance of the tooth was
literally injected with the colouring matter of the
blood, and this so effectually as to render every
effort to  restore  it to its natural  whiteness, per-
fectly ineffectual.
  In this condition of things, my attention was
directed  to an  examination into the causes of
these phenomena, and the  following,  whether
correct or not,  is the result at which I arrived.
In order  perfectly to comprehend the process, it
seems  necessary to premise, that the nerves, ar-
teries, and veins, which are destined to the teeth,
both of man  and animals, enter  them through a
minute  orifice or foramen at the extremity of
each root, and pass into a bony canal, which en-
larges  until  it  terminates in a  cavity in the
crowns of the teeth.  Now, in the act of drown-
ing, I consider  that the heart continues to pul-
sate after the lungs have ceased to play; conse-
quently,  the blood is propelled to the  head, until
the vessels are distended, and often ruptured, as
is frequently  the case with  divers, who remain
long under water,  the  blood bursting from the
eyes, nose, ears, and even from  the mouth.  In
death by hanging, or sudden strangulation, as in
the case of bullocks, the truth of this position is
corroborated  by the following facts, which, in
my mind, put the question bevond the reach of
doubt  So soon as  the drop falls, and the body
is suspended  from the gallows or otherwise, re-
spiration of course ceases.  Still the heart  con-
tinues, though  irregularly,  its action,  the very
first effort of which, after the return of blood, by
the compression of the jugulars, is checked, is to
force the blood into the arteries of the head, and,
consequently, into those of the teeth.  The result
is,  that the arteries  passing through  the minute
and unyielding  foramina of the roots of the teeth,
are so dilated, that the nerves and veins are com-
pressed  to such a degree that no blood can re-
turn by the latter.  In the subsequent effort, the
 vessels are completely injected; and ultimately,
not only the vessels of the teeth are injected, and
ruptured, but the bony substance of the teeth,
 the hardest and most compact in the human body,
is penetrated  by at least the colouring matter of
the blood. 
470
ASPHYXIA. (Theory of.)
  In a letter received from my much respected
 friend and professional confrere, the late Edward
 Hudson, Esq., dated Philadelphia, Sept 11,1818,
 he  observes—"In the small box you  will find
 eight very fine teeth, if they were not red.  I
 want your  opinion of what occasions this red-
 ness, premising, that the teeth  of all drowned
 persons are so, that I have examined."
  In my reply, dated Sept. 26,1818, I gave him
 a full explanation of the cause of those appear-
 ances, not only in the teeth of drowned persons,
 but also in the teeth of persons  that have been
 hanged, and in those of bullocks drawn to the
 slaughter by a rope round  the neck,  &c, and
 asked him if I should return the teeth to him.
 In  his letter and  answer to me, dated Philadel-
 phia, Jan. 31,1819, he observes—" I take the pre-
 sent occasion to assure you, that you are very
 welcome to the teeth I was so fortunate as to
 send you.  They are of use to you, and I have
 got some useful knowledge by a mere accident."
  In 1833,1 believe, two coloured persons were
 executed in this city—the one a male, the other
 a female, the latter for poisoning the wife of a
 medical gentleman.  These  subjects were ex-
 amined by myself and two  other medical gen-
 tlemen, after the heads had been in maceration
 seven weeks. The red appearance was strikingly
 obvious in all the  teeth that were examined.
  In the case of  a coloured man who was exe-
 cuted in this city,  last spring, for the murder of
 Capt----, these appearances of the teeth were
 equally evinced, and were, on that account, as
 I was informed, exhibited, by Dr. Wm. Baker,
 to his anatomical class."
  With regard  to the  duration of life in
 cases of asphyxia, or rather  to the  capa-
 bility of resuscitation, it is impossible  to
 say anything definite.   Where once  the
 heart has ceased to beat,  it is  extremely
 difficult  to restore it.   We know nothing
 whatever  of the  cause  of its action;
 but distension  by  an  appropriate  fluid
 appears to be indispensable: unless, there-
 fore, we can succeed  in  propelling the
 blood from tlie lungs to the left side of the
 heart, so as to  excite  there  the requisite
 stimulation,  our  efforts  at  resuscitation
 will be vain.  But although we may lay
 it down as a general rule, that  where the
 action of the heart has ceased, in asphyxia,
 for  a few minutes,  we shall too often fail
 in saving  the individual, much may de-
 pend  upon  a difference  of resistance  in
 individuals, referable to age, constitution,
 corporeal condition, &c.   It  is  probable,
too, that the more slowly the  state of sus-
pended  animation  has  been induced, the
greater will be the chance of restoration,
the organs retaining longer the power of
being reanimated.   In some of the varie-
ties, too, of asphyxia, lesions are apt  to
be produced, which inevitably destroy.
  It is important to bear in mind the cases
on record, in which resuscitation has been
 effected, as in drowning, after an immer-
 sion much  longer than that we have laid
 down as usually sufficient to render  as-
 phyxia irretrievable;  but  at  the same
 time, we must unhesitatingly reject many
 of the  marvellous stories that  have been
 handed  down to us on this subject,  and
 which, strange to say,  find believers even
 at the present day.  A modern writer (Ju-
 lia. Recherches,&.c. sur Vair marecageux.
 Paris, 1823.),—after quoting Herodotus to
 show that a person named Scyllias could
 readily travel two  leagues underwater;
 and Radzivil, who affirms that  he  has
 seen some  of the Egyptian fishermen re-
 main whole  days  under water, without
 rising to the surface to breathe; and after
 citing, amongst other stories almost equally
 incredible,  and  yet which he  seems to
 credit one from Dulac, ofa certain Fran-
 cois de la Vega, who  remained five years
 under water,  and  yet rose again, with
 life!—affirms, that no one is ignorant that
 the  drowned have  been  restored to  life
 after having remained forty-eight hours
 under water!—yet spite of  this mon-
 strous  credulity, M. Julia's work  was
 crowned by the Academie Royale des Sci-
 ences of Lyons, and received high com-
 mendations from  a friendly reviewer, for
 the great number of interesting facts it
 contains.
   Notwithstanding  traditionary  histories,
 and  the  philanthropic  recommendation,
 that our attempts at resuscitation should
 be continued for several hours in cases of
 asphyxia (Curry ; Wagner, in  Encyclo-
padisches Worterbuch  der medicinischen
 Wissenschaflen.  Band in. s. 555.; and
 others), it is but too true, that our efforts
 will generally be fruitless,  after a perfect
 asphyxia  of a few minutes' duration.
   Dr. Lefevre,  of Rochefort,  who  was
 lately stationed at Navarino, had  ample
 opportunity of putting  the  powers of the
 best divers to the  test  He witnessed the
 performances of those who were employed
 to fish up the relics of the Turkish fleet
 sunk in Navarino harbour.   The depth to
 which they had to  plunge was 100 feet;
but though the Greek divers are, and have
always  been, famous for their  prowess,
 none of them could sustain submersion for
two  whole  minutes together.   Seventy-
six seconds  was  the average  period  in
fourteen instances accurately noted; and
frequently,  after reaching the surface,
blood issued  from the mouth,  eyes, and
ears of the  swimmer.  But in general,
these people can  repeat their task three
or four times  in an  hour.  (London Med.
 Gaz. 25 July, 1835. p. 608.)
   2. Theory  of asphyxia.   It is all  im-
portant  to have  correct  ideas  regarding
the theory of asphyxia; for, according to 
ASPHYXIA.  (Theory of.)
471
the views entertained on the subject,  the
therapeutical considerations will  have to
be regulated.  It is a topic, too, full of in-
terest to the physiological pathologist and
one which has elicited much discussion.
Since the time of Bichat, however, the
views of that distinguished individual have
usually been implicitly adopted, until the
experiments and reflections of Edwards,
Williams, and Kay—especially of the two
last—have again revived the inquiry,  and
led to a  new and more philosophical  me-
thod of viewing the subject.
   Before  attention  was directed to  the
chemical phenomena of respiration, or to
the changes produced  on the blood in the
lungs,  it  was  generally  supposed, that
when respiration is suspended, the  circu-
lation ceases, owing to some mechanical
obstacle existing in the lungs, or to their
collapse; and  this view was even main-
tained at a  later  period.  (Coleman.)  It
was  soon, however, established,  that no
such mechanical impediment exists to the
passage of the blood  through the lungs,
even after the most forced expiration, and
that it continues to circulate freely through
them.  Accordingly, Goodwyn  rejected
this hypothesis, and having  properly ap-
preciated  the  importance  of the  conver-
sion of venous into arterial blood, and the
necessity of a due supply of the latter for
the maintenance of the circulation and of
life, he supposed, that in cases of asphyxia,
the blood, being no longer exposed to the
influence  of the air, and therefore retain-
ing its venous character,  is unable to sti-
mulate the  left auricle and ventricle to
contraction; the heart, consequently, in
his view,  becomes, as it were, paralyzed,
and dies first.
   In  Goodwyn's theory,  no obstacle is
conceived to exist to the circulation of the
blood through the lungs; the cause of the
asphyxia is  the nonconversion of venous
into arterial blood, and, as a consequence
thereof, the arrival, at the left side of the
heart of blood not possessing those quali-
ties that are requisite for exciting its cavi-
ties to contraction.
   This view of the phenomena of asphyxia
met with  considerable  favour from physi-
ologists,  and was generally adopted, until
the appearance of the  Researches of Bi-
chat on Life and Death;  but there were
many and cogent objections to it.   In the
first place,  if it were correct, we could
not assign any satisfactory reason for the
continuance, during the  whole  of exist-
ence, of the action of the right side of the
heart, whose cavities necessarily receive
only venous  blood.  Its presence  ought
to  paralyze  that  side of the  organ.
Again, as was properly suggested by Bi-
chat (Recherches sur la  vie et la mort.
p. 24.),  if the  dark blood  paralyzed the
left side of the heart, the heart's  action
ought to cease first, and that  of the or-
gans to follow, which is directly opposite
to the fact  To overturn Goodwyn's doc-
trine, Bichat instituted a series of admi-
rable experiments,  which satisfactorily
proved,  that the heart continues to act for
some minutes after respiration has ceased;
that during this period, blood of a dark co-
lour penetrates the  lungs, and proves a
sufficient stimulus to the left ventricle;—
and  he farther maintained—a point of
great moment connected  with his own
views on the subject—that this dark blood
is vigorously propelled by the heart through
all the arteries, and consequently through
every tissue of the body.   He  inserted a
stopcock into the windpipe of  a dog, and
having  exposed an artery, and divided it,
he closed the stopcock, so as to completely
prevent  respiration.  The  blood,  which
flowed from the artery, at first issued in a
full stream, and of a bright arterial hue;
but as the oxygen of the air, contained in
the minute bronchial  ramifications,  was
exhausted, the blood gradually lost its ar-
terial character, until  it  ultimately  pre-
sented  the  appearance of venous  blood.
The stream became  weaker, and smaller,
and at length ceased.   At the  expiration
of three minutes, even when  great loss
from  hemorrhage was avoided, he found
that but little blood flowed from the ex-
tremity of a divided artery,—and in five
minutes there was usually  not the slight-
est oozing; so that he inferred, the circu-
lation  continues  little more  than three
minutes after respiration has ceased, and
the state of asphyxia  terminates  in the
extinction of life  in five minutes.  From
this experiment it was clear,  that for a
time, the left heart acted vigorously with
nothing but venous blood in its cavities.
  Led by the  results  of these and  other
experiments, Bichat propounded a theory,
which,  if he had made no other contribu-
tion to  medical science, would have ren-
dered  his  name  celebrated amongst its
promoters.  He, equally with  Goodwyn,
ascribed the first link in the chain of phe-
nomena to  the nonconversion  of venous
into arterial blood; but  he rejected the
idea of Goodwyn, that any paralyzing in-
fluence is exerted upon the left side of
trie heart;  and attributed the whole of
the phenomena to the poisonous effects of 
472                         ASPHYXIA.  (Theory of*.)
the venous blood on the different tissues
of the body.   The principal points of his
theory were  the following:
  The venous blood, in a case of asphyxia,
is sent by the contraction of the right side
of the heart through the lungs, which at
first contain a  small quantity of air,  but
far too little  to  effect  its conversion into
arterial blood.   On reaching the left side
of  the heart, the blood stimulates it to
contraction,  and is transmitted along the
arteries  to  every part of the organism;
but as the appropriate stimulant  of these
organs is blood that  has  undergone  the
vivifying influence of the air in the lungs,
this unconverted, or partially converted,
blood is insufficient for the purpose, and,
indeed, is markedly stupifying and delete-
rious,  so that the organs finally cease to
act in consequence of being poisoned by
the blood sent to them.
   Again, the action of the nervous cen-
tres soon ceases, when venous  blood is
alone received by them.   If venous blood
be  injected into the carotid artery of a dog
by means of a syringe, the animal is found
to present signs of suffocation, analogous
to  those of asphyxia,  and  animal  life is
soon  entirely suspended.  The same re-
sult follows  the injection  of blood  taken
from the arteries of an animal in a state of
asphyxia.  Bichat therefore inferred, that
it is the contact of venous blood, and not
any want of impulsion communicated to
the brain, which causes the loss of sensa-
tion in an asphyxied individual; and this
he conceived to be confirmed  by the  cir-
cumstance, that if the brain of an  animal
be exposed, and respiration be prevented
by means of a  stopcock attached  to the
trachea, the movements, impressed on the
brain  by the pulsation of the encephalic
arteries, continue for some time after ani-
mal life, or  the  life of relation, has ceased.
He ascribes the head-ache, vertigo, &c,
which precede  the loss of consciousness,
to  the same  action of blood not hematosed
on the brain.
   When the brain has ceased to perform
its functions,  it  would follow,  that the
muscles and other organs  which receive
their nervous supply  from it as well as
from  the whole of the cerebro-spinal axis,
should have their functions abolished also;
but to this sufficient reason, Bichat adds
another—the presence of black blood in
their intimate structure,—of blood  which
is incapable  of  maintaining their contrac-
tion.   In proof of this,  he injected blood
taken from one  of the veins, into the  cru-
ral artery of an animal, after which its
movements were sensibly enfeebled, and
in some instances paralysis followed.
   But not only was this deleterious influ-
ence exerted upon the voluntary muscles;
a  like effect was exhibited on the invo-
luntary, or those of organic life.  Their
contractile power was equally annihilated,
but somewhat later.   Thus, the heart,
after having asphyxied  the  other organs,
by sending black blood  to them, becomes
itself asphyxied, owing to the black blood
penetrating its own structure through the
coronary arteries.
   Again, venous blood does not constitute
the proper pabulum for the various secre-
tions ; hence, nutrition  and secretion are
suspended; and, on this account perhaps,
the total quantity of blood in the body ap-
pears to be greater after  asphyxia  than
after any other kind of death.
   Such are the main points of the theory
of Bichat, which,  as has been remarked,
commanded  universal  assent for  a  long
period,  and which a  recent writer consi-
ders " to have alone merited the suffrages
of all physicians."  (Devergie. Art. As-
phyxie, in Diet, de Med. et de Chirurg.
Prat.)  Of late  years, however, it  has
been  subjected to a fresh examination, and
the labours  of Williams, Kay, and  Ed-
wards—especially of the two first—have
sufficiently shown, that many of the views
of Bichat have been  too  implicitly re-
ceived, and  that  some  of them should be
unhesitatingly rejected. The two points
that have been chiefly attacked, are,—his
assertion  regarding the permeability of
the vessels of  the lungs in asphyxia, and
that relative to the deleterious action of
the venous blood on the different organs,
and especially on the muscles.
   Dr. Kay, whose first  essays on this sub-
ject were published in a respectable British
periodical (Edinburgh Med. and Surg.
Journ. XXIX.), and who has since embo-
died his experiments and reflections in an
ex professo treatise ( The physiology, pa-
thology, and treatment, of asphyxia), de-
nies the correctness  of the first assertion
of Bichat, and maintains, that the earliest
effect of the interruption of respiration is
to impede and arrest the circulation of the
blood in the capillary system of the lungs.
   All the organs of the body, in his view,
consist of a congeries  of small blood-ves-
sels, denominated,  from their minuteness,
' capillaries.'  These vessels are possessed
of peculiar powers, by which, in a healthy
state, they admit only  fluids of a certain
quality, excluding  those that are incom-
patible with  the functions of the part 
ASPHYXIA.  (Theory of.)                        473
 They even resist the forcible introduction
 of other fluids, when injected with a sy-
 ringe.   In the lungs, minute blood-vessels
 exist in an exquisitely delicate net-work.
 In  these vessels, the venous blood is ex-
 posed to the influence of the atmospheric
 air; its qualities are changed; it loses its
 dark hue,  and acquires a bright  red co-
 lour, and hence,  Dr. Kay thinks it proba-
 ble, that the vessels in which the  arterial
 blood circulates, must differ in their pecu-
 liar sensibilities,  from those  which propel
 the venous blood.  The laws generally ob-
 served to regulate the action of the small
 vessels in other structures, would,  he con-
 ceives, be violated, if the vessels which
 usually convey arterial  blood,  were able
 to convey, with equal facility, venous blood
 in  every state of its changes, until it ac-
 quires its darkest colour.  When air is no
 longer inspired, a considerable quantity of
 this fluid remains  in the ultimate bron-
 chial subdivisions, and so long as  this air
 contains a certain portion of oxygen, the
 blood undergoes its proper change in the
 pulmonary  vessels,  and the circulation
 proceeds with its ordinary activity; but as
 the proportion  of oxygen diminishes, the
 conversion is more  and more imperfectly
 accomplished;  the  circulation becomes
 progressively feebler, and slower, " until,
 when  venous blood enters those  vessels
 which formerly  conveyed arterial  blood
 only, this degenerated fluid  is no  longer
 able to excite their action, and the circu-
 lation  stagnates  in the structure of the
 lungs.  The pulmonary  veins  then dis-
 charge their last meagre supply through
 the left auricle  into the left  ventricle,
 which propels  its  last and  feeblest tide
 into the arteries,  in which the circulation
 has, every moment become more  scanty,
 until the pulsation has gradually been ex-
 tinguished." (Kay.  Loc. Cit. p. 21.)  In
 this way, Dr. Kay accounts for the con-
 gestion of the venous system, and espe-
 cially of the right side of the heart, and
 of the pulmonary artery, whilst his theory
 equally explains the emptiness of the pul-
 monary veins,  and  the left side  of  the
 heart.
  In confirmation of his views, Dr. Kay
 cites an experiment of Bichat, adduced
 by  the  latter gentleman  to show,  that
 black blood passes freely through the pul-
 monary vessels.   He inserted a stopcock
 in the windpipe of a dog, and having laid
 bare an artery and divided it, he  closed
 the  stopcock, so as to prevent respiration.
 The blood  flowed from  the  vessel, for a
 time, with  its usual force, but at  length
the jet became gradually feebler.  On re-
admitting the air, however, the blood be-
came almost immediately red, and  its jet
visibly augmented.  " In this experiment,"
says Dr. Kay, "the exclusion of air is not
continued so long as to produce a perfect
abstraction  of the  oxygen remaining in
the air cells, when the stopcock is closed;
nor to extinguish the  respiratory powers,
the manifestation of which is resumed as
soon  as  the stopcock  is  reopened.   The
blood, changed  in colour, but not  yet so
much impaired in its qualities as to be un-
able to traverse the lungs, still circulates,
and air is admitted at a moment when the
danger  of the  occurrence of asphyxia is
imminent, but when the respiratory pow-
ers and the organic functions are  still sup-
ported by a  blood partially oxygenated."
(Kay. p. 25.)
  Again, if after  a  ligature has been
tightly drawn  around  the trachea of an
animal, a large artery—as the  crural or
the aorta—be  opened, the flow  of blood
from  the vessel  soon  stops, and yet the
heart continues to contract energetically;
the arrestation  of the hemorrhage being
dependent upon the left side of the heart
ceasing to receive a supply of blood from
the lungs.
  From  these and other  facts,  Dr.  Kay
concludes, that as soon as the conversion
of venous into arterial  blood is arrested in
asphyxia, the blood gradually ceases to
permeate the pulmonary vessels; and in
a few minutes, the left side of the heart,
no longer receiving a sufficient quantity
of the fluid, ceases to contract.
  It  is proper to remark here,  that, al-
though  Dr.  Kay has but slightly alluded
to the fact  in  his Treatise on Asphyxia,
many of his  conclusions had been  antici-
pated by Dr. Williams, of Liverpool, as
long  ago as the year  1823.  In  an inte-
resting  communication published by that
gentleman in the Edinburgh Med.  and
Surg. Journ., the following positions are
laid  down,  and  most  successfully illus-
trated :—First.  The blood is obstructed in
its passage through the lungs on suspen-
sion of respiration, whilst its circulation
through  the other parts of the body  con-
tinues.   Secondly. The obstruction of the
blood in the lungs,  on suspension of re-
spiration, is  not the effect of a mechanical
cause.   Thirdly. The obstruction  of the
blood in the lungs,  on suspension of re-
spiration, arises from a deprivation of pure
atmospherical air.  Fourthly. The blood
which is found post mortem in the left au-
ricle  and ventricle, is  the remnant after
the last systole, and the subsequent drain-
ing of the pulmonary veins.  Fifthly. The 
474
ASPHYXIA.  (Theory of.)
obstruction of the blood  in  the  lungs, on
suspension of respiration,  is one of the
principal causes of the vacuity of the sys-
tem circulating arterial blood post mortem.
Sixthly. The immediate cause of the ces-
sation of the action of the heart is a pri-
vation of its natural stimulus, arising from
the obstruction  of the blood in the lungs.
   The view of Drs. Williams  and Kay
is entirely opposed  to  that  of Bichat,
which  it is destined, doubtless,  to  sup-
plant. It is more in accordance with what
we know of the physiology of the heart's
action, which has ever been a deeply in-
teresting question with  the physiologist,
and,  in  the obscurity of the subject, has
given rise  to various and  warm contro-
versies.   By many of the ancients it was
supposed to be  owing to some unknown
but inherent pulsific virtue,  which  ena-
bled  the organ to contract and dilate al-
ternately, but why or wherefore was  not
known,  or  attempted to  be  explained.
Others ascribed its action to an explosion
which was fancied to take place in the
ventricles; others to an imaginary archae-
us, whilst Haller considered there was a
vis insita in the muscular fibres of the
heart which was excited to action by the
stimulus of the blood.   It would seem as
if the stimulus of distension  were  alone
necessary,  in certain  cases at least  to
keep up the contraction of the organ.  Dr.
J. K. Mitchell being engaged  in dissect-
ing a sturgeon, its heart was taken out,
and laid on the ground,  and, after a time,
having ceased  to beat,  was inflated with
the breath, for the purpose of drying it.
Hung up in  this state, it began to move,
and continued for ten hours to pulsate re-
gularly,  though more and more slowly,
and,  when last observed in  motion,  the
auricles  had become so dry  as to rustle
when they  contracted  and dilated.   He
subsequently repeated the experiment with
the heart of a Testudo serpentaria,  or
snapper, and found  it to beat well under
the influence of oxygen,  hydrogen, car-
bonic acid, and  nitrogen, thrown into it in
succession.  Certain agents were found,
however, to destroy the irritability of the
organ sooner than others.   Water, for ex-
ample, stimulated it,  perhaps more strong-
ly, but made its substance look pale and
hydropic, and in one minute destroyed ac-
tion beyond recovery.  (American Journ.
Med.  Sciences. VII.  44, 58.)
   The second position of Bichat, and the
one on which he placed more reliance, and
exhibited more  ingenuity in his attempts
to establish it—relative  to the deleterious
influence of venous blood on the different
organs, and especially on the muscles—has
been equally contested, and overthrown.
  Many years ago, Dr. W. F. Edwards,
of Paris (De  Vinfluence des agens  phy-
siques sur la vie. Paris, 1824.), attempted
to ascertain the  comparative duration of
life in frogs whose  hearts had  been cut
out, and in  those in which they were left
untouched.  By  placing  them  in water
deprived  of air,  the latter, in  some  in-
stances,  lived twenty hours longer  than
the former,  so that the circulation of ven-
ous  blood  was  manifestly favourable to
their existence,  instead of being delete-
rious, as Bichat presumed.
   Dr. Kay's  experiments  on this subject
are full  of  interest  He properly objects
to the few experiments on which Bichat
rested his opinion regarding the delete-
rious effects  of black blood on muscular
contractility,—that  sufficient  discrimina-
tion was not employed to discover whether
the effects were  caused by cutting off the
supply of arterial blood, rather than  from
the  presence of venous blood.   To show
that the effect is entirely owing to the
ligature of the artery, he performed the
following experiments.
   In three rabbits, the abdomen was open-
ed.  The aorta of one was tied above the
renal arteries, and also  the left common
iliac close to the aorta.  In eight minutes,
the vena cava of the second was opened;
and the  blood, which flowed, was injected
into the aorta of the first.  The contrac-
tility of both  extremities was found  to be
equally vigorous. At the  fourteenth min-
ute, the degree  of contractility having
been ascertained, by the insertion of nee-
dles attached to the wires of a galvanic
battery, another  quantity of blood was in-
jected.   No difference whatever could be
detected in the  contractility of the  mus-
cles of the two  extremities.  The injec-
tion of venous blood, obtained from the
cava of the  third  rabbit was  repeated
twice  more in the  course of thirty min-
utes.  At each interval between the in-
jections,  the  wires  were  applied to  the
muscles of both extremities,  when  their
contractility was found  to decline gradu-
ally, and equally, in each, as in experi-
ments in which the artery was simply tied.
Some feeble contractile power existed for
one hour.  Desirous, however, of com-
paring the effect on the muscles, and with
the blood, of the same animal, cateris pa-
ribus,  he instituted the following experi-
ments, under the feeling, that if the blood
of asphyxia, or black blood, have a  more
baneful  influence on the  muscular  func-
tions than the want  of arterial blood, con- 
ASPHYXIA. (Theory of.)
475
tractility ought to cease sooner in the for-
mer than in the latter case.
  A ligature  was placed around the tra-
chea of a rabbit, and one around the ab-
dominal aorta, above where the superior
mesenteric artery is given off.   These li-
gatures were applied nearly at the same
moment.   All  the  muscles  continued
equally vigorous on the application of the
galvanic stimulus.   They then equally
and gradually declined in excitability, and
in one hour  lost all evidences of it, the
muscle of the upper extremity appearing
towards the close of the experiment to be
somewhat stronger. This experiment was
repeated, and it was subsequently varied.
The trachea  of one rabbit was tied, and
the heart of another had a ligature passed
around its base.  This occupied one min-
ute.   The  muscles continued contractile
an equal time  in both.   Dr. Kay conse-
quently infers,  that the supply of dark
blood from the left heart has no positively
noxious influence  on  the  muscles; and
that they are  affected precisely in the
same manner, and degree,  as when the
supply of blood to their tissue is prevented.
He found also,  that the presence  of as-
phyxial or venous  blood in the voluntary
muscles supports their  contractile power
for a considerable period. (Kay. Loc. Cit.
p. 154.)  Farther   experiments  induced
him to conclude, that venous blood appears
to be even capable of supporting the func-
tions of the nervous system for a short pe-
riod, but a short period only.   Its propul-
sion into  the cerebral  vessels soon pro-
duces languor and feebleness,  but still, he
conceives, the venous blood does not exert
a positively noxious influence on the nerv-
ous system,  nor destroy its  faculties by
mere contact, like a foreign fluid.   In as-
phyxia, the imperfectly arterialized blood,
which circulates through the brain,  is less
conducive to  the maintenance of its func-
tions than arterial blood; but  those  func-
tions, and life itself, are abolished, because
the circulation  is arrested  in the  lungs
when  the  respiratory phenomena  cease.
The fluid, which  is  then  propelled into
the nervous tissue, though less capable of
developing its powers than arterial blood,
can maintain, for  a time,  imperfect mo-
tions of the vital parts,  and contribute to
the evolution of an inferior order of phe-
nomena, (p. 207.)
  It appears  manifest then, we think, that
Bichat has attached too much importance
to the presence of black blood in the dif-
ferent  tissues,  and  that the  mischief is
rather  to be  ascribed to the  absence of
blood in the arteries.  Were  the experi-
ments and observations of Edwards, Kay,
and others,  considered insufficient to  es-
tablish this, the singular phenomena  ex-
hibited by malignant cholera would com-
plete the demonstration.   They are  cal-
culated, indeed, to give the dernier coup
to the theory of Bichat, and to shake all
our ideas regarding the connexion of  the
sensitive  and locomotive  functions with
the circulation and hematosis.  (Berard.
Diet, de  Med. IV. 235.)  Every one who
has witnessed that strange malady, must
have  observed  the  nervous  and mus-
cular actions  preserved  until  within a
few  moments  of dissolution, when  the
whole  of the vascular system  has been
so filled  with black  blood,  as  to ren-
der the  surface blue, and when arterial
pulsations, even in the larger vessels, have
been imperceptible.   These striking phe-
nomena  have,  indeed, led M. Magendie
to affirm, that the contact of arterial blood
is neither indispensable to cerebral action
nor to muscular contraction; and a recent
writer (Madden's Infirmities of Genius,
chap. 13.) has gone so far as to assert that
the brightening up of the mind  prior to
dissolution,  which is occasionally witness-
ed, but  far less  frequently than is ima-
gined, is probably produced by the " sti-
mulus"  of  the dark  venous blood circu-
lating through the arterial vessels of the
brain; but this idea  is opposed to all the
received  notions  on  the  subject.  (See
Death.)
   The general conclusions which Dr. Kay
deduces  from all  his  investigations, are:
First.  That  the  circulation is arrested
after respiration ceases, because, owing to
the exclusion of oxygen,  and the conse-
quent non-arterialization of the blood, the
minute pulmonary vessels, which usually
convey arterial blood, are incapable  of
transmitting venous  blood, which there-
fore stagnates in the lungs.   Secondly.
That the arrestation of the circulation is
sudden when the lungs are entirely  de-
prived of air, and that blood ceases to flow
from them  into  the  left  cavities of  the
heart,  even in the smallest quantity, in
about three  minutes and a half.   Thirdly.
That even  supposing a great quantity of
venous  blood were transmitted  through
the lungs, it would not  impair  their con-
tractility ; but, on the contrary, it is even
capable of supporting this power for a cer-
tain period.  That venous blood does  not
possess any noxious quality, by  which the
organic functions  of these tissues can be
destroyed, but  is simply a less nutritious
and less stimulating fluid than arterial
blood: and  lastly,—that the functions of 
476
ASPHYXIA. (Treatment.)
the muscular fibre cease in asphyxia, be-
cause the  circulation,  and consequently
the supply  of the fluid which is necessary
to life, is arrested in the lungs.

   Such are the  chief theories that have
been indulged on this  interesting subject.
Of these, that of  Dr. Kay is decidedly the
most logical, and best supported by facts.
Were that of  Bichat adopted,  vainly
might we  attempt resuscitation by infla-
tion of the lungs,  seeing  that every tis-
sue, even that  of the heart has been poi-
soned to the total destruction of its irrita-
bility.  This, indeed,  has  generally been
regarded as  a  powerful objection  to the
view of that distinguished  physiologist.
   In the present state of our knowledge
of asphyxia, we are justified in regarding
the arrestation of  pulmonary circulation
in the capillaries as the first consequence
of the nonconversion of venous into arte-
rial blood; the  flow  of arterial  blood to-
wards the left heart  is consequently ar-
rested; and again, as  a consequence  of
the want of the stimulus of distension, the
left cavities lose their  contractility; the
right auricle, which  continues for a time
to receive blood  by the venae cava?, being
the ultimum moriens, not the left  side of
the heart,  as has been  asserted by some.
(Copland. Art Asphyxy.)  The nervous,
muscular,  parenchymatous, and  other tis-
sues, no longer receiving  a  supply of ar-
terial blood,  cease  also  to act; but those
organic  functions  which  are effected  in
the capillaries of the general system—as
nutrition,  secretion,  and  calorification—
yield last; circulation continuing  in the
capillaries for some time after it has ceas-
 ed in the larger  vessels.
   These  are probably the chief agencies
 concerned in the phenomena of asphyxia.
 One  of the  first effects, consequent upon
 the obstruction of  the capillaries, and the
nonconversion of the blood  in the lungs,
is the  affection  of the  brain; but as Dr.
Roget has properly remarked (Cyclopa-
dia of Pract. Med. I. 170.),  if this were
the sole effect directly produced  by the
want of oxygen, or superabundance of car-
bon in the  blood, asphyxia might be ranged
 under the  head of apoplexy;  and the sub-
sequent failure  of the circulation would
be a consequence of the impaired  energy
of the nervous powers that  maintain the
action of the heart   But the motion  of
the heart,  in asphyxia,  is arrested much
 sooner than  in  simple apoplexy.  In the
latter disease, the heart continues  to beat
for hours,  and even days, after the aboli-
tion of sensation and consciousness,—and
it  appears  ultimately to stop,  chiefly in
consequence of the cessation of breathing,
which always takes place when the aboli-
tion  of the powers  of  voluntary  motion
has proceeded a certain length. " So that,
in fact,  it may more  properly be said, that
apoplexy proves fatal by inducing a state
of asphyxia,  than that asphyxia is merely
a species of apoplexy, as it has been erro-
neously classed  in some systems of no-
sology."
   3.  General Treatment.   An attentive
consideration of the different phenomena
of asphyxia,  presented during life as well
as after death, and a comparison  of these
phenomena with  the theory they seem so
naturally to suggest, will  leave but little
doubt in the mind of the  practitioner, as
to the general resuscitative measures he
ought to adopt.  Still there are many par-
ticulars in which doubt might be indulged,
and  on which, indeed,  a diversity of opi-
nion yet exists amongst therapeutists.
   The  general  indications  will  consist,
first, in removing the individual from the
causes  that have produced the asphyxia;
and secondly, in endeavouring to restore
respiration, circulation,  and innervation—
the great vital functions, which mutually
react on each other, and therefore require
the simultaneous application of remedies
adapted to each.
   The  consideration of the mode of ful-
filling the  first indication will necessarily
fall under the examination of the  particu-
lar varieties  of asphyxia, as it must differ
in each variety.
   The chief means for fulfilling the sec-
ond are,—to expose the body to  that de-
gree of heat which experience has shown
to be best  adapted for the support of the
vital powers, and simultaneously to at-
tempt to restore  the suppressed  respira-
tion.
   a.  Temperature.   For the  purpose of
determining the  temperature, &c.  best
calculated for this object the experiments
of Edwards  afford us  some valuable aid,
These experiments were instituted on dif-
ferent classes of animals, but the pheno-
mena in all are of interest, as regards the
present inquiry.   His first topic of inves-
tigation was asphyxia as it occurs in the
batrachian reptiles; and especially, whe-
ther  the medium in which it may  take
place has  any  peculiar influence,  inde-
pendently  of that which is exerted on the
lungs.   The most important of these me-
dia, as respects the frequency of their ap-
plication, are air and water;  and as the
batrachian reptiles have the power of liv-
ing  a considerable  time after the heart 
ASPHYXIA.  (Treatment.)                       477
has been removed  from the body, the re-
spective influence  of these media can be
readily appreciated.  By the  removal of
the heart, the respiratory and circulatory
functions are annihilated; the  nervous and
muscular systems are alone left, and these
are inseparably  connected.   By placing,
therefore, batrachian reptiles, whose hearts
had been  removed, in air and  in  water,
and observing how long they continued to
live in each, a comparison could be drawn
of the influence of these media on  the
nervous and muscular systems, independ-
ently of that which they exert on circula-
tion and respiration.
   This experiment was performed  on sa-
lamanders, frogs, and toads.
   Two salamanders,  deprived   of their
hearts, were placed in water  of the same
temperature, which had been deprived of
air by boding; and two in air: one of the
former died in eight hours,—the  other in
nine; whilst  those in air lived from 24 to
26 hours.  The experiment was repeated,
with  similar  results;  whence Dr. Ed-
wards infers, that  air, in comparison with
water, has a superior vivifying influence
upon  the  system of those animals,  inde-
pendently of its action  by means of circu-
lation and respiration.
   Similar experiments  on frogs  furnished
analogous results.  Those in water lived
two hours; those in air, three. If a frog,
thus deprived of its  heart, and immersed
in water,  be taken out and exposed to the
air, at the moment when all signs  of life
have  disappeared,  it  immediately begins
to recover. If it be  again plunged in water,
every appearance of  life instantly ceases,
and it may thus be made,  several times
alternately, to lose, and recover, its mo-
tion and sensibility;—circumstances which
strikingly confirm  the vivifying effect of
air, and the deleterious influence of wa-
ter, on their  nervous and muscular sys-
tems.
  In another experiment, Edwards stran-
gled a number of frogs by means of a li-
gature passed round  the neck.   At first,
they were paralyzed,  but they afterwards
recovered in  a great degree, and lived
from one to five days.
  It  would seem,  from these and  other
experiments, that batrachian  reptiles can
live for many days  by the aeration  of the
blood  effected through the skin, and by
the action of the air on the nerves distri-
buted  to  the  cutaneous envelope.   That
the blood is acted upon  by the air, was sa-
tisfactorily shown by  the quantity of car-
bonic acid exhaled  from the surface of the
body, when strangled frogs were placed
in receivers containing atmospheric air,—
a fact clearly showing the existence of
cutaneous respiration in them.
  The result of all  these  experiments
was  materially modified, however,  by va-
rious circumstances, and one of the most
important of these was  the temperature
of the medium.  It was found, that as the
temperature  of the water of immersion
was  reduced, the duration of the life of
frogs was prolonged, until, at 32° of Fahr-
enheit, or the freezing-point of water, it
was  more than tripled.   On  the other
hand, elevation of the temperature occa-
sioned a  corresponding  abbreviation of
life,  until, at  108° of Fahrenheit, or about
the natural temperature  of many  warm-
blooded animals, death  was almost in-
stantaneous.
  It appeared, too, that season had a ma-
nifest influence on the duration of life;—
first, by  the  temperature  of the water in
which the animals were  immersed; and
secondly,  by  the influence of the tempe-
rature of the air, for some days previous
to the experiment; and when these cir-
cumstances were combined, the effect was
doubled.   On the 23d of November, 1817,
the air and water being at 50° Fahr., and
the mean temperature of the month being
nearly the same, five frogs were placed in
water at  the same degree.   They lived
from 5h.  10' to llh. 40'; the latter period
being about double the duration of life of
these animals in summer, in water at the
same degree.  On the 22d of December,
the thermometer having been about 32°
Fahr. for twenty days, three frogs were
put into water at 50° Fahr.  They lived
from 20 to 24 hours.   On  the 23d of De-
cember, the  temperature  being  still 32°
Fahr., four frogs were placed in water at
32° Fahr., the same  apparatus being em-
ployed as in the preceding experiments.
They lived from 24 to 60 hours.  In the
last  experiment, consequently, they were
placed in circumstances the most favour-
able  for prolongation of life under  water.
  Experiments were made on fishes, simi-
lar  to  those  on the  batrachian  animals;
and first  as regards the influence of tem-
perature  on their lives in water deprived
of air.  Comparative  experiments were
made on  individuals of the same species,
at temperatures varying  from 32° Fahr.
to 104°.   The result was,  that at the
higher limit, death was as speedy as in
the case of the batrachians, and the dura-
tion  of life was progressively greater in
proportion as  the temperature was reduced
towards the lower limit.  It seemed, how-
ever, that the smaller and the  younger 
478                       ASPHYXIA. (Treatment.)
the fish, the less  capable were they of
bearing an elevation of temperature.  At
104°, the small fish did not live more than
two  minutes, whilst the  larger survived
several minutes longer.
  Dr. Edwards's  next inquiry was—into
the influence of the temperature of aer-
ated water, in limited quantities, on fishes,
in close vessels; and  from a number of
well devised and  well executed experi-
ments,  he deduced the following  infer-
ences : first, that the duration of life goes
on  increasing  with an  increase in the
quantity of aerated water,  the tempera-
ture remaining the same: secondly, that
the  same result  takes place  when, the
quantity of water remaining the same, the
temperature is  lowered:  and thirdly, that
the  duration of life remains  the  same,
when, within certain limits, we increase
or diminish,  at the same  time, both the
temperature and the aerated water.
  The  influence  of the  temperature on
fishes was found to resemble that on the
batrachian reptiles.  If a bleak (Cyprinus
alburnus) be put into a vessel with a large
mouth, containing five ounces  and a half
of aerated water, at 68° Fahr. in summer,
it dies within a few hours; but when the
temperature is lowered to 50° or 53° Fahr.,
and is kept at that point the animal lives
until its secretions are so abundant as to
corrupt the water; and if the water be
renewed every twenty-four hours, it lives
in it almost indefinitely.
  From all his experiments on fishes, Dr.
Edwards deduces, that the more the tem-
perature is raised, beyond a certain limit
the greater is the  degree of influence of
the air required for their support
  Thus far, his experiments have referred
only to the cold-blooded  animal.  Those
that  relate  to the warm-blooded,  are
equally ingenious  and instructive.
  It has been a universal opinion, owing
to the circulation of young animals being
more rapid, and the function of nutrition
more  active,  that their  temperature is
much  higher than  that of adults.   The
opinion is not  sanctioned by observation.
When  new-born animals  are  examined,
the  temperature,  if placed  near the mo-
ther, is never found to be superior to that
of the adult.   But if, when the tempera-
ture is from 50° to 68° Fahr., a new-born
puppy be removed and kept  an  hour or
two from its mother, the temperature falls
considerably, and continues falling, until,
in the  course  of three or four hours, it
stops at a very  few degrees above that of
the  surrounding air. . The heat begins to
subside as soon as the  separation  takes
place, and the diminution is not in the
least retarded by furnishing the animal,
from time to time, with milk.  It would
appear, consequently, from these and other
experiments, that the young, of certain
animals at least, produce less heat in a
given time than the adult As the animal
advances in life, the difference, under the
circumstances  mentioned, occurs more
slowly, and to a less and less extent until,
at the  end of a fortnight, it can maintain
itself at a temperature  nearly equal to
that of the parent.  The new-born puppy
would  seem, therefore, to resemble the
cold-blooded rather than the warm-blooded
animal, the  characteristics of the latter
being acquired gradually.
  The same phenomena were found to
take place with  kittens and rabbits, but
not with the young of all the mammalia—
with the young Guinea-pig, for example.
  The young of the  mammalia seem to
be divided into two groups, in  relation to
animal heat; some being born, as it were,
cold-blooded, others warm-blooded; and,
corresponding to this difference, there ap-
pears to be another,  deducible from the
state  of the  eyes.  Some are born with
the eyes closed; others with them open;
and until the eyes are opened they resem-
ble the cold-blooded  animal,—those that
are born with the eyes open being warm-
blooded from birth.  "Thus,"  says  Ed-
wards, "the state of  the eyes, though
having no immediate connexion with the
production of heat, may yet coincide with
an  internal  structure  influencing that
function,  and  certainly furnishes signs
which serve  to indicate  a remarkable
change in this respect;  since, at  the pe-
riod of the opening of their eyes, all young
mammalia have nearly the same tempera-
ture as adults.   (Edwards.—Hodgkin's
Translation,  p. 70.)
  The  power of producing  heat  seems
consequently, in warm-blooded animals, to
be  at  its  minimum  at  birth,  and it  in-
creases, according to Edwards,  succes-
sively  until adult age.   Farther experi-
ments  appeared to  show, that continued
elevation  of temperature diminishes the
power of producing heat, whilst an oppo-
site state  of the  air, provided the cold be
not too severe, increases it.
  The hope of producing such a change
in animals, as might enable them to  sup-
port the privation of air for a much longer
period than is natural to them, and to be-
come,  as  it were,  aquatic  animals,  led
Buffon to the discovery of a singular fact
connected with young animals. He placed
a greyhound bitch  of the large  species, 
ASPHYXIA.  (Treatment.)
479
when on  the point of  giving  birth  to
young, in a tub of warm water,  and se-
cured her in such a manner that she was
obliged to bring them  forth under water.
These were afterwards,  for the sake of
nourishment, transferred  to a smaller tub
of milk, but without giving them time to
breathe.   They remained there for above
half an hour, after which  they were taken
out and all  found  alive.   They began to
breathe, which they were permitted to do
for half an  hour,  and were then again
plunged in the milk, which had,  in  the
mean time,  been warmed again.   There
they remained for another half hour, and
when they were again  taken  out  two
were quite strong, and seemed not to have
suffered at all. The third appeared droop-
ing,  but  was carried to  its mother, and
soon recovered.  The experiment was con-
tinued on the other two: they were al-
lowed to breathe a second time for about
an hour,  and  were  then plunged once
more in the warm milk  for half an hour,
after which  they appeared as strong  as
before.  Being taken to the mother, how-
ever, one of them  died the same  day,
whether from accident or the privation of
air could not be  ascertained.  The other
lived, as well as the first; and both throve
equally with the other puppies, produced
after  the  bitch  was  removed  from  tlie
water, and which  had not been experi-
mented on.
   Similar experiments were made by Le
Gallois, on rabbits, which would favour
the belief, that the  duration of the life of
new-born  mammalia, under such circum-
stances, is about half an hour.   But M.
Edwards was surprised  to  find, that the
Guinea-pig, at birth, when plunged in wa-
ter, lived only three or four minutes longer
than the adult,—and  in other animal spe-
cies  the difference was not greater.   On
examining into the cause  of this, he found,
that those animals which,  when asphyxied,
give signs of life for half an hour, are the
very species  that  possess feeble powers
for the production of heat,—new-born dogs,
cats, and rabbits, for example.  It was be-
fore  observed, that these  animals,  at this
period  of their existence, strongly resem-
ble cold-blooded animals,  and these facts
show that they resemble  them farther in
the power of sustaining  privation of air.
On the other hand, Guinea-pigs are in the
class that produce most heat at birth, and
of these, Edwards says he has never seen
one that lived above seven minutes under
water.  In them, at the  end of the  fifth
day from birth, the duration of life in as-
phyxia is  reduced  one half; and this re-
duction corresponds to a sensible elevation
of their temperature.   The same thing is
observable  after another interval of five
days.  The heat is  then much augmented,
and the power of  living without respira-
tion greatly diminished; and when they
have attained the  fifteenth day, a period
when they ordinarily possess a tempera-
ture  nearly equal  to that of adults, they
scarcely differ from them in the duration
of asphyxia.  If instead of passing at once
from the first to the fifth day, we examine
the animal on the intervening days,  we
find, that during the first, and second, and
not unfrequently the third, the duration
of asphyxia is but slightly altered. The
production  of heat corresponds with this,
and both phenomena likewise concur in
the more  marked  and rapid change that
takes place soon after.
   The distinction pointed out  between
young mammalia,  founded on the produc-
tion  of heat is therefore applicable to
them  also  in respect to the  duration of
life, when respiration is cut off.  This  du-
ration has  its maximum in the group of
mammalia  that produce  the least heat at
birth, and its minimum in those that pro-
duce the most.
   The external temperature has likewise
an influence on the duration of  life in
these cases.  Kittens, when a day or two
old, were subjected to water cooled to  32°
Fahr.: they ceased to give signs of sensi-
bility and  motion  after four minutes  and
thirty-three seconds,—taking the mean of
nine experiments.   At a temperature of
50° Fahr., the duration  of life extended
to ten minutes and twenty-three seconds,
and at 68°, to thirty-eight minutes  and
forty-five seconds.  At 86°, however, they
lived but twenty-nine minutes, and at 104°,
but ten minutes and twenty-seven seconds;
—so that  there are  two great conditions,
that  influence the life of warm-blooded
animals when deprived of air,—the quan-
tity  of  heat developed  by the animals
themselves, and the external temperature
to which they are exposed.
   In. the  modifications of heat in man,
from birth to adult  age, a striking analogy
is perceptible to warm-blooded animals in
general.   Those that are born with  the
eyes closed lose their heat, when they  are
exposed to the air in  spring or summer,
almost as rapidly as  the cold-blooded ver-
tebrated animals; whilst those whose eyes
are open at  birth, under similar circum-
stances, preserve a high and constant tem-
perature.   In accordance with analogy, a
new-born  infant, at  the  full period, as it
has the eyes open, ought to have the power 
480                        ASPHYXIA.

of maintaining a pretty uniform tempera-
ture during  the  warm seasons;  but if
birth should take place at the fifth or sixth
month,  the case is  altered; the pupil is
generally covered with the membrana pu-
pillaris, which places the  animal in a con-
dition similar to that of closure of the eye-
lids in other  animals.  Analogy would in-
duce  us to conclude, that in such an in-
fant, the power of producing heat would
be inconsiderable.   Observation confirms
this;  although we obviously have not the
same facilities, as in the case of animals,
of exposing the young to a depressed tem-
perature.   On taking the temperature of
twenty adults, it was found  to vary from
96° to  99° Fahr.—the  mean being 97°;
whilst the  temperature  of ten healthy in-
fants  varied  from 93° to 95° Fahr.—the
mean being  94° 5;  and the temperature
of a  seven  months' child,  though well
swathed, and near a good  fire, was, within
two  or three hours  after  birth, no  more
than 89° 6 Fahr.  Before the  period at
which this infant was born, the membrana
pupillaris disappears; and it is probable,
as Edwards has suggested, that if it had
been born some time before the disappear-
ance  of the  membrane, its power  of pro-
ducing heat would  have  been so feeble,
that it would scarcely have differed from
that of mammalia  born  with  the  eyes
closed.
   These facts are  important in the pre-
sent inquiry, but they are not the less so
in their application to the influence of cold
on mortality at different periods of life; a
subject treated of elsewhere. (See Cold.)
   A great point of information, conveyed
by the experiments of Le Gallois, as well
as by those of Edwards, is, that there  ap-
pears to be always a certain ratio between
heat and respiration  in both the cold-blood-
ed and warm-blooded animals, and in  hi-
bernating animals both in the periods of
torpidity and of full  vital activity.  When
the eighth pair  of nerves is cut in the
young  of  the  mammalia, a considerable
diminution is produced in the opening of
the glottis,  so that, in puppies recently
born, or one or two days  old, so little  air
enters the lungs, that  when the  experi-
ment is made in ordinary circumstances,
the animal perishes as quickly as if it was
entirely deprived of air.   It lives  about
half an hour.  But if the same operation
be performed upon  puppies of the  same
age, benumbed with cold,  they will live a
whole day.  In the first case, according to
the view of Edwards, the small quantity
of air is insufficient to counteract the ef-
fect of the heat; whilst in the latter it is
(Treatment.)

sufficient to prolong life considerably; and
he deduces the following practical infer-
ences applicable to the adult age, and par-
ticularly to man.  "A person is asphyxied
by an excessive quantity of carbonic acid
in the air which he breathes: the beating
of the pulse is no longer sensible;  the re-
spiratory  movements  are not  apparent;
but the temperature is still elevated. How
should we proceed, to recall  life! Al-
though  the action  of the respiratory  or-
gans is no longer visible, all communica-
tion with the air is not cut off.  The  air
is in contact  with the skin, upon which it
exerts its vivifying influence:  it is also in
contact with  the lungs,  in which it is re-
newed by the agitation which is constantly
taking place  in the atmosphere, and by
the heat  of  the body, which rarefies it
The heart continues to beat and  maiu-
tains a certain degree of circulation,  al-
though not perceptible by the pulse. The
temperature  of the body is too high to al-
low the feeble respiration to produce upon
the system all the  effect of which it is
susceptible.  The temperature must then
be  reduced; the patient must  be  with-
drawn from  the deleterious atmosphere,
stripped  of his clothes, that the air may
have  a more extended action  upon  his
skin; exposed to the  cold although it be
winter, and  cold water thrown upon his
face until the respiratory movements  re-
appear.   This is precisely the treatment
adopted to revive an individual in a state
of asphyxia.   If, instead of cold, artificial
warmth  were to be applied,  it would be
one of the most effectual means of extin-
guishing life. This consequence, like the
former, is confirmed by experience.  In
sudden faintings, when the pulse is weak
or imperceptible, the action of the respira-
tory organs diminished, and sensation and
voluntary  motion suspended, persons the
most ignorant of medicine are aware, that
means of refrigeration must be employed,
such as exposure to air, ventilation, and
sprinkling with cold water.  The efficacy
of this plan of treatment is explained on
the principle before laid down.  Likewise,
in violent attacks of asthma, when the ex-
tent of respiration  is so reduced that the
patient experiences a sense of suffocation,
he  courts  the cold,  even in the most se-
vere weather; opens the window; breathes
a frosty air, and feels relieved." (Edwards,
Lib. Cit.,  and Hodgkin's Translation, p.
149.)
  It is obvious from all the experiments
of Edwards, that  an elevated tempera-
ture of the body exhausts the nervous ac-
tion, unless the animal is able, at the same 
ASPHYXIA.  (Treatment.)
481
time, to have a due supply of air, and that
there  is a  temperature,  remote from the
extremes of too great heat and too great
cold, which is best adapted for the  reco-
very of those  in  whom respiration has
been from any cause arrested.   When the
management of the different varieties of
asphyxia  fall under consideration,  this
subject will have to be again  referred to,
in its  relation to  each;  and  its bearings
on the asphyxia of the new-born infant, or
of one thrown into a state of suspended
animation  in the first few days of its ex-
 istence, will be strikingly apparent  In
all varieties of asphyxia,  a temperature at
all approaching that of  the body,—and a
 higher than  this has been recommended
 by the Royal Humane Society of London
 (Report for 1833.  p.  100.),  whose  direc-
 tions are  the rule of conduct  over every
 part of Great Britain at least—must, for
 the  reasons  assigned, be positively inju-
 rious, and a fortiori,  if such elevated tem-
 perature  be applied  through  a medium
 that shuts off from the skin the vivifying
 influence  which the  contact of air  is ca-
 pable  of exerting.  In but few cases can
 it be safe to have the air of the apartment
 higher than 75° or 80°, and in some of the
 varieties, one of which has been specially
 designated by Edwards, it may be  much
 lower than this.   Radiant caloric, where
 it is demanded, is manifestly to  be pre-
 ferred to the conducted, unless its  appli-
 cation, in the latter way, be partial, so as
 not to interfere greatly with the free  ex-
 posure of the surface to the contact of air.
 The body may be placed  before the fire, or
 in the sunshine; and warm  flannels, or
 bags of warm grains, or of salt or sand;
 or bottles of warm water, or warm bricks,
 may be placed on small  extents of the cu-
 taneous surface.   A proper temperature
 might be  applied  to the back by the tin
 mattresses, filled  with warm water, used
 during the  prevalence  of the cholera in
 several of the cholera  hospitals.  In this
 partial mode of applying warmth, suffi-
 cient  surface is allowed for the action of
 the air, as well as for the employment of
 friction, which, with  some other agencies,
 and especially that of artificial respiration,
 are the grand  means  for  restoring sus-
 pended animation. (Kay on Asphyxia,  p.
 40.)
   b. Insufflation.  We  have  said, that
 the application of warmth must be made
 simultaneously with another  operation,—
 the most  essential,  indeed, of the  appli-
 ances and means that  have  been recom-
 mended for the removal of asphyxia.
   It must be recollected, that in this con-
   VOL. II.          41
dition, respiration and circulation are sus-
pended, and that innervation, which is un-
der the dependence of these two functions,
is almost annihilated.  Irritability,  how-
ever, still exists, whilst the blood-vessels,
and the cavities of the heart, contain ve-
nous, and usually liquid, blood.  Unless,
indeed, this were the  case, and if fibrinous
concretions had formed in the cavities and
in the great vessels, all attempts at resus-
citation would manifestly be fruitless.  In
all these cases, death has supervened on
the arrestation of a single vital function
intimately catenated  with  the  rest, but
views have  differed  regarding the first
seat of death: fortunately,  under every
view that has been entertained in modern
times, the same plan  of management has
been inculcated.  At one period,  it was
universally supposed,  that death, in drown-
ing, Is owing to the oppression of the wa-
ter swallowed; but as soon as the labours
of Detharding, Plater, and others, show-
ed that this was  an error, and that death
results  from the privation of air, pulmo-
nary insufflation was  recommended. The
theory  of Goodwyn  (Connexion of life
with respiration, p. 111.), as before shown,
maintained, that the  contractile power of
the left heart is destroyed, owing to ve-
nous blood being sent  into it.  Accord-
ingly, insufflation was proposed, to change
the quality of the blood  in the pulmonary
veins,  sinus  venosus  and  auricle,  to
blood capable of arousing the left heart to
contraction.  Goodwyn's erroneous views
of the  nature of the affection  led him,
however,  to  the  injurious  recommenda-
tion, to introduce a  large quantity of air
at each inflation—upwards  of  100 cubic
inches,  for example, in the case of the
adult;—a recommendation which,  if uni-
versally  embraced,  could not  fail  to be
followed by  the  unhappy  consequences
that are found  to  result  from an inju-
dicious  employment  of  artificial respira-
 tion.  Bichat, Kay,  and indeed every au-
 thor on the subject whatever may be the
 theory he adopts,—equally recommend its
 employment.  Under the view embraced
 by Kay, it is clearly the most philosophical
 plan of treatment that  could be devised.
 Asphyxia, it has been seen, essentially re-
 sults from the privation  of air preventing
 the due conversion of venous into arterial
 blood; and, as a result of this, stagnation
 taking place in the pulmonary capillaries.
 To remove  such stagnation, and re-estab-
 lish the flow, this conversion must be ef-
 fected ; after which,  arterial blood makes
 its way through the  vessels adapted for it,
 but  which did not allow the passage of 
482
ASPHYXIA.  (Treatment)
venous blood, and in this way, the circu-
lation, when it has not been too long sus-
pended, may be restored.
   The most simple mode of employing ar-
tificial respiration is that proposed by Le-
roy,  and which has since been described,
at length, in the latest reports of the Royal
Humane Society of London.  It has a sig-
nal advantage  of being available in cases
where no professional individual is at hand,
and can always be employed without the
slightest  apprehension of evil.
   A piece of strong flannel, an old blan-
ket  sheet, or other  cloth,  most  easily
attainable at the moment, is to  be cut
of the following size, and in the  follow-
ing  manner.   It  should  be six feet in
length, and in breadth eighteen  inches.
Six strips are then to be cut or torn length-
wise  on  each side.  Each strip is to be
three  inches broad,  and two feet long.
The  untorn portion (two feet in  length,
and eighteen inches broad) is to be placed
under the back of the patient from the
armpits to  the upper part of the thigh
bones.  The strips are then to be brought
together over the chest and abdomen, in-
terlacing  each other  from the  opposite
sides,  as  the  fingers are interlaced in
clasping the hands.  The strips, thus  ar-
ranged, are to be gathered into a bundle
on each side,  and if they are then drawn
in opposite directions by two assistants,
the edges of the bandage will be made to
approach,  and firm and  equal pressure
will be produced on  the  chest and ab-
domen.
   The assistants—having thus compress-
ed the body of the patient by drawing the
bandage  in opposite  directions,—should
then  relax  it,  permitting the chest to re-
expand,  and performing  this process at
the rate of about twenty times in the min-
ute.   If the head and shoulders be  ele-
vated, the contents of the abdomen, on the
relaxation of the  pressure, will cause the
diaphragm  to  descend by their  gravity,
and will thus enlarge  the chest.   By ap-
plying the  flame  of a candle, or the fine
down of a feather, to the mouth and nos-
trils,  it will be seen, that on each firm
pressure by the bandage, air  is expelled
from tlie  lungs;  and on the relaxation of
this pressure, the chest regains its original
size, and air rushes in.
   Such is the plan, which may be had re-
course to  almost  from the first moment
that the body is discovered, and whilst any
other means are in preparation from which
more  beneficial effects are anticipated:
but as soon as it can be accomplished, a
more  effective  method of re-exciting the
respiratory movements should be adopted.
The pipe  of a pair of bellows  may be in-
serted into one nostril, whilst  the' mouth
and  opposite  nostril are closed  by an
assistant  and the windpipe, in the supe-
rior  prominent  part, commonly  called
Adam's apple,  is gently pressed back.
Then,  by forcing air into the lungs, and
alternately expelling it  by  pressing the
chest  respiration may be imitated.  In
this way,  air may be sent into the lungs
about twenty times in the minute, so as
to imitate natural respiration as nearly as
possible.
  Another, and a more satisfactory method
of insufflation,  is, to  pass into  the larynx
a bent silver canula,  the larger extremity
of which can be attached to the end of a
flexible tube, so as to admit ofa ready ex-
ecution of the process.   The finger must
be passed  towards the root of the tongue,
on which  it must press; in this way, the
epiglottis  is raised, and, by carrying the
canula along the finger, it readily slides
into the larynx.  To facilitate this opera-
tion, Leroy  has devised an instrument,
represented in the annexed figure, for de-
pressing the tongue and elevating the epi-
glottis.   This instrument is composed of
two parts articulated at a, Fig. 1.   The
branch b b is fixed; that of c d movable.
When the extremity c is elevated towards
b, the extremity d is depressed, and  is
made to act on the base of the  tongue so
as to elevate the epiglottis.
  Fig. 2. represents the canula 1 1 in its
place.  It is  attached to the fixed branch 
                           ASPHYXIA.

by a ring, / and at  the other end it fol-
lows the motions of the other branch, to
which it is attached by another ring, g.
By the movement of this branch, and the
corresponding  depression of the  base of
the tongue, and elevation of the epiglottis,
the canula is  directed to the opening of
the larynx, into which  it can be readily
made to enter.
   Such  an instrument however, can be
rarely necessary, and it will probably be
no more used  than the various modifica-
tions of the bellows, that  have been re-
commended  by  Gorcy,  Ruland,  Kopp,
Configliacchi, and others.
   Where none of the apparatus we have
described is at hand,—but this can rarely
happen, for in almost all situations, a ban-
dage, of the kind recommended for estab-
lishing artificial respiration,  can  be met
with,—it has been advised, that air should
be forcibly blown into the lungs, by apply-
ing the mouth of the operator to that of
the patient, closing his nostrils with one
hand,  and gently expelling the air again,
by pressing the chest with the  other, or
by the aid of an assistant;  and if any dif-
ficulty be experienced in this method, air
may be blown  in at  one nostril, keeping
the other closed, and pressing the larynx
back upon the  oesophagus, in the mode al-
ready described, so as  to prevent the in-
troduced air from passing down into the
stomach:  or one of the curved  canulas
may be  introduced, and air sent through
it But this method has not met with the
approbation of every observer, and for ob-
vious reasons.   When the  air issues from
the lungs of an individual, it has experi-
enced such a change in its composition as
to be no longer adapted for continued re-
spiration.  It is true, that it loses not more
than three parts of its oxygen, which are
replaced by carbonic acid gas.  Still, it
has ceased to be the appropriate fluid—at-
mospheric air—for the maintenance of the
respiratory function, as experiments on
animals sufficiently demonstrate.  On the
other hand, the introduced air has its tem-
perature elevated, so that  the advantage
of the  higher  temperature,  it has  been
conceived, may nearly counterbalance the
disadvantage of less purity (Copland. Art.
Asphyxy, p. 133.); but this we have seen
may be  advantageous or disadvantageous
according to the case.   It is more than
doubtful, indeed, whether in any case of
asphyxia, in the adult the application of
a  temperature of upwards of 90° to the
body can  be useful.  Berard considers
that the danger or dread  is slightly ex-
aggerated, as the air is so little changed,
(Treatment.)                       493

and moreover,  in  spite of every precau-
tion, where a tube is not used, the air
must pass,  more or less, into the pharynx
and even into the oesophagus, so  that it
cannot enter in quantity  into the lungs.
(Art. Asphyxie, in Diet, de Med. IV. 240.)
  The advantages, however, attending the
insufflation of the  pure air  of the atmo-
sphere, are so overwhelming, that it ought
always  to  be  adopted, when practicable.
There is, indeed, one variety of asphyxia
where such deteriorated air can hardly be
looked  upon as objectionable;—the as-
phyxia of the new-born child, or  of one
that has respired but for  a short  period.
The presence  of a full portion  of oxygen
is not here so  indispensable as it is after-
wards;  but this variety will have to be
considered hereafter.
  At  one  period,  pulmonary insufflation
was universally practised,  and without the
slightest cautions.  It was  even  recom-
mended, as has been just observed, that
the air should be forced into the lungs so
as to penetrate the minute air cells; and
it  is somewhat  surprising, that after the
anxious consideration which had been pre-
viously  given to the  subject and which
was even at the time given to it by  physio-
logists,  Dr. Roget (Cyclopadia of Pract.
Med.) should  have inculcated the  same
forcible measures, without any qualifica-
tion whatever. " The object," he remarks,
" being  to introduce pure air into the in-
most recesses of the air cells, so as to ex-
ert a chemical  action upon the blood in
the pulmonary  vessels, some  degree of
force  must be used in order  to overcome
the mechanical  obstacles  to its admission.
For this purpose, a considerable quantity
of air should be introduced at each  infla-
tion ;  for,  as Dr. Goodwyn observes, if
only twelve cubic inches  be injected at a
time,  this  small quantity  will occupy the
larger branches of the trachea, and con-
sequently only a small number of the pul-
monary vessels will be exposed to  its ac-
tion :  but if a much greater quantity of
air be forced in at each time,  some  of  it
will pass  into all the more remote cells;
and when they are thus uniformly dis-
tended, the pulmonary veins, the  sinus
venosus, and left auricle, will be exposed
as much as possible to its action, and  some
of the  arterialized blood  may be forced
into them from the capillary vessels."
   Of late, however,  it has been  shown,
that the  apparently simple  operation of
inflating the lungs is not as devoid of dan-
ger as was for a long time imagined; and
it has been attempted to prove, that many
cases may have resulted  fatally from the 
484                        ASPHYXIA.  (Treatment.)
violence  of the  insufflation, and  conse-
quent lesion of the pulmonary structure.
(Kay on Asphyxia, p. 43 and p. 226; and
Magendie,  in Journal de Physiologie,
IX.  105.)  Some of the  statistical  evi-
dences on which this  opinion  is founded
will be  given under the section  on As-
phyxia from  submersion.
   Bichat had remarked, that where air
is forced violently into the lungs of an
animal, infiltration of air may be produced
owing to rupture of some  of the pulmo-
nary vesicles, and, within the last few
years, M. Leroy d'Etioles  has instituted
a series  of experiments, which have con-
firmed the observations of Bichat. (Jour-
nal  de  Physiologie, VII. and  VIII.; and
Rapport sur  un Mimoire de M. Leroy
d'Etioles, relatif a Vinsufflation du pou-
mon, &c,  par MM. Magendte et Dume-
ril, in Revue Medicale, XIII.) He found,
that  if air was blown into the lungs, and
with no greater strength than that  of an
expiration from the human lungs, it proved
fatal to rabbits,  foxes, goats,  sheep, and
other animals.  The experiment was per-
formed by briskly inflating the lungs from
the mouth of the operator.  All  animals
were not, however, equally affected by
the operation.   The  tissue of the  lungs
of the dog, for example, is denser than in
 the animals mentioned, and therefore re-
sists the insufflation better; and the same
 remark  applies  to  the lungs of infants,
 which were not  lacerated, even when the
 inflation was  practised with considerable
 force,—a fact which was confirmed by the
 experiments  of  MM.  Magendie  and Du-
 heril.  Similar experiments, made on
 the dead bodies of adults, exhibited that a
 like rupture  of  the air cells could  be ef-
 fected by simple oral insufflation.
   Where the pulmonary vesicles are rup-
 tured in this manner, the air passes into
 the cavity of the pleura, and presses upon
 the lungs, so that they cannot be  inflated,
 unless  the effused air be  removed by  a
 puncture made  in the chest, and then re-
 inflating the lungs by the trachea. A post
 mortem examination of many of the cases,
 that proved  fatal  after insufflation,  suffi-
 ciently  exhibited  their  true  pathology;
 the  diaphragm  being  found  pressed into
 the  abdomen, so as to form a prominent
 elastic tumour in that cavity, and  the lung
 contracted into a small space in the chest.
   In the experiments on animals,  relief
 was afforded by making a puncture through
 the  parietes  of the  chest,  immediately
 after brisk insufflation had been practised,
 and thus permitting the effused air to issue
 from the cavity of the pleura. The ani-
mals,  treated in this manner, recovered,
although they exhibited much embarrass-
ment  in breathing for some hours.
  To remedy these  inconveniences, Le-
roy has recommended a  modification of
the resuscitative apparatus.   He employs
the double-valved bellows of Hunter, to
the handles of which he  has adapted the
graduated  arc of a circle.  One end of
this arc is attached to one handle of the
bellows, whilst the other passes through a
mortice-hole in the other handle.   The
extent to which the handles are separated
is measured by  the  graduated  arc, and
thus the quantity of air sent into the lungs
may  be determined.  With his bellows,
he  measured  the quantity of air expired,
without effort, into  a bladder, by persons
of different ages, and marked upon the
arc of the circle the point to which the
handle  of  the bellows was raised in each.
He moreover had the curved tubes, to be
introduced into the glottis, made of a dif-
ferent calibre, according  to the age, so as
to  render  it  impossible to introduce the
proper quantity of air, as  indicated on the
arc of  the bellows,  more rapidly than it
would be inspired at that  age.
   The  apparatus is simple, and its adop-
tion  has been properly and strongly ad-
vised, on  the ground,  that verbal  direc-
tions often fail to impress the mind with a
due sense  of the dangers attending insuf-
 flation,  especially when  it must be per-
formed in such excitement and confusion,
 a6  cannot fail occasionally to diminish the
 caution even of experienced persons. (Kay
 on Asphyxia, p. 230.) In most of the cases
 of asphyxia, however, that occur* no such
 apparatus can be at hand,  and the operator
 is  consequently  constrained to make use
 of the  agents which present themselves.
 These  should of course be employed with
 the  greatest precaution, to prevent the
 evils that have  been depicted by Leroy.
   In adopting any form  of msufflation it
 is important to imitate, as far as possible,
 the natural movements of inspiration and
 expiration; not  to go on incessantly for-
 cing air into the lungs, but by means of
 the  pressure before mentioned, to force
 the air from the chest before a fresh quan-
 tity is sent in.   This is one of the strong
 objections that may be urged against the
 plan, which has been recommended, where
 difficulty is  experienced  in introducing a
 curved  tube into the glottis,—of making
 an incision into, the windpipe, and  insert-
 ing the nozle of the bellows into it so as
 to maintain artificial respiration. In order
 that  expiration shall be accomplished, the
 nozle  must  necessarily  be alternately 
ASPHYXIA.  (Treatment.)
485
withdrawn and inserted, so that great vio-
lence  must be done to the parts.  A fatal
case of this kind is given by Mr. Franks.
(Observations on animal life  and appa-
rent death.   London, 1790.   8vo.)
  Lastly,  it  has been  recommended  to
substitute oxygen gas for atmospheric air,
and that the resuscitative apparatus should
contain a quantity in a well-stopped bottle
(Wagner.  Art Asphyxie,  in Encyclop.
Wbrterb.) ;• but although it might seem
probable, that the substitution of oxygen
would be advantageous,  so few cases  of
its employment  are on record, that Mr.
Armiger, when  about  to prepare a work
on suspended animation—which  has not
yet seen the light—solicited from the pro-
fession accounts of cases successfully  or
unsuccessfully treated,  but  his  call  was
not responded to. (Lond. Medical Reposi-
tory, Jan. 1822.)  Goodwyn employed this
gas in several instances in asphyxia of the
smaller animals, and he thought  that re-
covery was  commonly more expeditious
than where atmospheric air was used; but
at the same time he admits, that he had
never been able to resuscitate an animal
by oxygen gas,  after atmospheric air had
been vainly employed.
  We can readily appreciate  the princi-
ple on which inflation  with oxygen gas
should be recommended; but it  is not  so
easy to comprehend that on which Acker-
mann should advise  a mixture of 80 parts
of atmospheric air, and 20 of  chlorine
(Schrift. uber den Scheintod u. s. w.), un-
less it were upon the same principle  that
Hinter (Observations on the animal eco-
nomy, p. 136.) advised the inhalation  of
stimulating  vapours.  The recommenda-
tion appears, however, to have fallen still-
bom from its originator.
  c.  Excitants.  Agents of this kind were
sure to have early suggested themselves.
The vital powers being suspended, or,  as
it was conceived, in a state of torpor, ex-
citants would naturally  seem  to be de-
manded in every case of asphyxia.  Fric-
tion has been advised by all, although, Dr.
Roget remarks, its importance, even as  an
auxiliary means  of restoring  life,  may
have  been  much  overrated.   (Art. As-
phyxia, in Cyclop. Pract. Med.)  It  can,
of course, be of no  use where the circu-
lation has entirely ceased in the capillary
vessels; but in  such a case all applica-
tions  would probably be equally unsuc-
cessful: when,  however, even an obscure
circulation goes on in them,—and we have
seen that this may be the case for some
time  after the  action  of the  heart has
ceased,—the remedy is certainly philoso-
                  41*
phical, if used with the more important
means already considered.
  The effect of frictions, like that of local
excitants  in  general, is to produce rube-
faction, or, in other words, to solicit  the
blood into the extreme vessels, so that an
impulse  is   thus  communicated to  the
greater  and more important  parts of the
vascular system;  whilst the excitation of
the subcutaneous nerves is communicated
to the brain,  and  thence to every part of
the organism.  In such cases, therefore,
as admit  of any  hope of relief, the em-
ployment  of  friction may be  strongly  in-
culcated.  It may  be  applied with  the
naked warm hand,  previously dipped in
flour, to prevent abrasion; or  by the flesh-
brush.  The  part of the body that may
be selected  with this object is not ma-
terial, but generally the extremities  are
recommended.
  Various other  excitants have been ad-
vised, such as tickling the nostrils or the
fauces with a feather; applying spirits of
hartshorn or aromatic vinegar  to  the
Schneiderian membrane by the same  in-
strument ; burning sulphur under the nose
of the patient, as well as other volatile ir-
ritants; but  they can be of  little  or  no
use  until the sensibility is  restored  by
other means,—and then they  are probably
unnecessary.
  With similar views, brandy and water,
or hartshorn and water, or  negus, have
been thrown into the stomach by means
of the stomach tube; and  irritating tur-
pentine or spirituous enemata, or salt, or
vinegar, or chlorate of potassa in solution,.
have been administered in the same form.
Their use can only be productive of bene-
fit under like circumstances, and they
had  better be cautiously employed in all.
  The effect  of electricity, in the different
forms in which it is adopted  in medicine,
on the functions  of sensibility, and mus-
cular contraction, could not fail to suggest
it early to observers as a means for  re-
storing suspended animation.   It is doubt-
less  a most valuable agent, but is rarely
available,  for reasons that are obvious.  J.
P. Frank, Thillaye (Archives Gen.  de
Med. XII.), and others, have strongly  re-
commended it; the  latter gentleman  on
the strength  of numerous experiments on
animals.   As the object in these cases, is
to arouse the respiratory muscles to  ac-
tion,  the  electric shock may be passed
through  the shoulders, or  through  the
chest in any direction.   Neither common
nor  galvanic electricity is  possessed  of
any  power   in  restoring the action  ot
the  involuntary muscles.  We have  tre- 
486                        ASPHYXIA. (Treatment.)
quently attempted to re-excite the ac-
tion of the  heart,  intestines,  fibres of
the uterus, &c,  soon after the cessation
Of respiration and  circulation,  by  means
of the galvanic stimulus, but without the
slightest success, although the voluntary
muscles responded to it most energetically.
Beside, were the action of the heart to be
re-excited by  it, this could  be but mo-
mentary.    An  appropriate  stimulating
agency is distension, and unless the re-
spiratory  movements  were restored, and
conversion of venous into arterial blood
effected, so that the latter could reach the
left heart, the  action  of that  organ could
not be maintained.  Every attempt, there-
fore,  is properly made to  restore the ac-
tion  of the  respiratory  muscles, so that
haematosis may be accomplished.
   It  has  been  advised,   that  the great
nerves should be  exposed in  the neck;
and that whilst the wire,  connected with
one pole of the galvanic battery, is ap-
plied to the  pneumogastric nerve,  for ex-
 ample, the other wire should  be placed on
 the epigastrium.  It is probable, however,
 that  every effect would be produced by a
 simple incision  through the  integuments
 of the neck, into  which the wire might
 be passed.
    M. Leroy d'Etioles has  suggested  a
 new method of  application, which, at the
 first aspect, appears to be most formidable,
 but is really less so than it seems, in con-
 sequence of the  impunity  with which fine
 needles can be  made to  penetrate  even
 the most important organs. (See Art. Acm-
 puncture.)  He introduced  an acupunc-
 ture  needle on each side, between the
 eighth and  ninth  rib, until they reached
 the  fibres of the  diaphragm.  He then
 established  a galvanic current between
 these, by  means of a pile of 25 or 30 pairs
 of plates, an inch in diameter.  The dia-
 phragm  immediately contracted,  and  an
 inspiration  was made.   He  then inter-
 rupted  the  circle, when the diaphragm,
 urged by the weight of the abdominal vis-
 cera, and aided by gentle pressure made
 on the abdomen by the hand,  returned to
 its former position, and an expiration was
 accomplished.   In this way, the  two  re-
 spiratory acts were made to  succeed each
 other, and  regular respiration was re-in-
 duced.   A  continuous current was like-
 wise applied  in some cases, but the  re-
 spiratory  movements were irregular, and
 nothing like natural respiration resulted.
    Leroy tried his method on animals  as-
 phyxied by submersion,  and when they
 had  not been under water more than five
 minutes,  they  were  often  resuscitated.
The experiments were witnessed by Ma-
gendie. (Journ. de Physiol. IX.)  On dif-
ferent occasions, M. Leroy asphyxied ani-
mals  of the same species, and apparently
of  like strength,  and whilst those that
were left to themselves  perished, those
that were treated by galvanism recovered.
   As an aid,  therefore, to pulmonary in-
sufflation, and  an important one, galvan-
ism might be advantageously employed in
asphyxia;  but,  as has  been already re-
marked, it can rarely be available.   Cer-
tainly no time  should be lost in adopting
the other energetic and indispensable mea-
sures that have been already advised.  It
has been recommended,  that  as  only a
very  small apparatus is necessary,  batte-
ries, consisting of a few plates, might be
kept  wherever there  are  station-houses
for the reception of persons in a  state
of asphyxia.  (Kay on Asphyxia, p. 232.)
The  suggestion is good; and they might
with propriety also form a part of the ca-
binet of apparatus of the private practi-
tioner ; but whilst an assistant is preparing
it  for action,  the practitioner should be
energetically  engaged  in applying hjs
other means of resuscitation.
   d.  Bleeding.   This operation requires
much caution, when practised to anything
like  the extent of an ordinary bleeding;
but there are  perhaps few cases of as-
phyxia,  in which blood can be  abstracted,
where the loss of a few ounces would not
be beneficial, along with the other resus-
citative measures. The venous system is
always surcharged with blood, and  the re-
 moval of this  quantity could scarcely fail
 to aid in the  re-establishment  of the cir-
 culation, without the danger of its extin-
 guishing vitality, that has been  appre-
 hended.  It is a measure,  however, re-
 garding the  propriety of which,  much
 difference of  opinion  has existed.  Mr.
 Hunter strongly reprobated it and the
 Royal Humane Society of London recom-
 mend the " utmost caution" in  its employ-
 ment.  On the other hand, Wagner (Art.
 Asphyxie, in  Encycl.  Wdrlerb.)  regards
 the removal of the oppression of the en-
 cephalon,  owing to the accumulation of
 blood in its vessels, as  the second indica-
 tion  to be fulfilled in  many kinds of as-
 phyxia, the first  being the restoration of
 the circulatory and respiratory movements.
 It has already been remarked, that the ab-
 straction of some ounces  of blood  must
 usually be beneficial in aiding the restora-
 tion of the circulation; but the grand evil,
 after all, is the deficiency of fluid  sent by
 the arteries, which bleeding can only rec-
 tify indirectly, by aiding in the re-establish- 
ASPHYXIA.  {Treatment.)
487
ment of the circulation.  A recent writer
affirms, that when the individual has only
just lost all consciousness, a " large bleed-
ing" may produce  the  most satisfactory
results,  and that if it cannot always be
employed at  the first, it often facilitates
the restoration of the circulation, when
attempts at respiration are made. (Dever-
gie, Loc. Cit. p. 550.)  The general re-
probation of  blood-letting  in  asphyxia
seems  scarcely  warranted;  and  indeed,
as  we  have  already  said,  there  are
perhaps few cases,  in which a moderate
abstraction of blood would  not  be bene-
ficial.

  Such are the chief remedial agents em-
ployed in asphyxia.  We  have said no-
thing of stomach-brushes,  and  stomach-
mops, for stimulating that organ; of the
internal use of phosphorus,  as suggested
by Dr. Good (Study of Medicine); of the
instillation of hot water on the head, scrobi-
culus cordis,  genitals,  spine, &c. ;  the
dropping of hot sealing-wax on the head;
sticking needles under the nails; the ap-
plication of the  actual cautery, &c.—be-
cause these are forms of excitants,  from
which  but little good could,  in any  case,
be expected,  whilst there are others that
are more appropriate in all.
  With regard to the length of time that
the resuscitative measures should be con-
tinued, it is difficult to lay down any pre-
cise rule.  We  shall find, when the par-
ticular forms  of asphyxia are considered,
that, in some, restoration appears to have
been effected after a greater lapse  of time
than in others, so as to have given rise to
the idea, that the impression, made on the
nervous  system by the cause  producing
the asphyxia,  may  have occasioned syn-
cope rather than true asphyxia. Under the
possibility, that restoration may still be ac-
complished in very  unpromising cases,  it
has been advised, that the means should
be persevered in for several hours, and
indeed, until  cadaveric rigidity begins to
appear.
  A good deal  must necessarily  depend
upon the length of time the individual has
been exposed  to the agency that has  occa-
sioned the asphyxia;  and the practitioner
in every case will  have to be  guided by
his own judgment as to the probability of
success from  the application of any re-
storative measures; bearing in mind the
cases on  record of recovery after a long
suspension of the vital manifestations, but,
at the  same  time, recollecting, that such
fortunate  examples are  extremely  rare.
Occasion, however, will present itself for
a recurrence to this subject.
  When  the resuscitative measures are
beginning  to be successful, slight con-
vulsive snatchings of the respiratory mus-
cles will take place  at longer  or shorter
intervals; with  gaspings, sighing,  slight
fluttering at the heart palpitations; and
afterwards regular respiration, and circu-
lation.  The patient, however,  should not
be abandoned by  the practitioner imme-
diately after resuscitation has occurred,
as,  in consequence of the  condition in
which the encephalon  has been placed,
during the existence of asphyxia, and the
irregular movements occurring during re-
covery,  delirium or convulsions may su-
pervene.  A case is given in a respectable
French periodical (Archives Gen. de Med.
Juin,  1829.), in which  the most  furious
delirium came on immediately after re-
suscitation  from  drowning, and where
blood-letting appeared to be clearly indi-
cated.  This will have to be judged  of by
the presence of the  usual signs, that de-
note  increased action of the  encephalic
vessels.
  Dr. Paris, too (Life of Sir Humphry
Davy, 4to. edit. p. 69.), gives the case of
a corporal of the guards,  who was seized
with  cramp  as  he was  bathing, and re-
mained  for several minutes under water.
By judicious assistance he recovered, and
appeared  to  those about him  to be free
from danger, when he was attacked with
convulsions and  expired.   Dr. Roget sug-
gests, that if the respiration had been ar-
tificially supported at this period, so  as to
have  maintained the action  of the heart,
until  the black blood had returned from
the brain, it is  probable, that the life of
the soldier  might have  been preserved
(Cyclop, of Pract. Med. 1.181.); but it is
more  probable, that some lesion had taken
place in  the encephalon, consequent on
the modified circulation in that viscus, ra-
ther than on the presence of black blood in
the vessels, which must  have been  sent
back  towards the  heart from the first re-
establishment of the circulation,—and this
view  is confirmed by the fact that con-
vulsions sometimes  occur a considerable
time  after recovery has, to all appearance,
been  effected.
  Various inflammatory symptoms are apt
to supervene, owing to the same irregu-
larity,—which must be met as they arise,
until  the  functions  are  restored to the
healthy condition.
  Bibliography.—Hensler, (Gabr.)   Anzeige
der hauptsiichtichsten Rettungsmitiel denerdie auf 
488
ASPHYXIA.  (Varieties of.)
ptotzliche  Unglucksfdlle leblos geworden sind.
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videntur  in vitam  iterum  resuscitari possunt.
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&c.  Sixty Reports.

   5 2. Of the varieties of Asphyxia. The
remarks made, in the history of asphyxia
in general, will render it  unnecessary to
dwell, at any great  length, upon the dif-
ferent varieties.   Respecting the number
of these, the greatest discrepancy has ex-
isted, in consequence of the difference of
latitude  given  to the  acceptation  of the
term.  The causes, previously referred to,
will guide  us  in  establishing a few  varie-
ties -.—first, those that arise  from any me-
chanical obstacle  to the due expansion of
the chest;—secondly, such as are depend-
ent upon an  insufficient supply, or upon
total  absence, of oxygen in the inspired
air;—thirdly, those that are produced by
irrespirable gases;—and fourthly, such
as  are  owing to any mechanical  cause,
which  prevents the  entrance of air into
the lungs.
   1.  The  brief  allusion,  that  has been
made  to the  first of these,  will be suffi-
cient It can  rarely happen, that asphyxia
is induced by any extrinsic cause, that can
prevent the due expansion of the chest in
inspiration, and therefore, as a question of
therapeutics or of legal medicine, it is
possessed of but  little  interest  whilst its
pathology does not differ from that  of as-
phyxia in  general.   As,  however,  death
takes  place in  consequence of  imperfect 
ASPHYXIA.  (From Want of Oxygen.)                 489
hematosis, and supervenes gradually in-
stead of suddenly, as in many of the other
forms of asphyxia, the evidences on dis-
section may  be more equivocal;  there
may not be the same extent of fulness in
the right heart, or of vacuity in the left;
nor ought we to expect  those  extravasa-
tions into the lungs or encephalon, which
are so common whenever the circulation
from the  right side of the heart to the left
has been suddenly arrested.
   Allusion has been already  made to the
cases in which this variety of asphyxia has
presented itself,—namely, as a punishment
in Turkey, and as a means of judicial com-
pulsion, where  a witness has persisted in
 remaining  wilfully mute.  Occasionally,
 too, it has happened, that this mode of ta-
 king away life has been adopted criminally
 with  the infirm, as in some  of those in-
 famous examples of turpitude, which ex-
 cited so  much horror and alarm, in the
 British metropolis,  a few years ago.   In
 these cases of refinement of cruelty, after
 the victim had been ' hocussed'—as it was
 termed in the  slang vocabulary—by stu-
 pefying him with opium in some form, the
 hand was pressed upon the mouth so as to
 prevent the entrance of air, whilst the ex-
 pansion  of the chest was prevented  by
 sitting upon the body.  In this way, death
 was as  speedy as  if a ligature had been
 passed around the neck, or  the individual
 had been thrown  into an irrespirable me-
 dium.
   2. Of  the variety of asphyxia, which is
dependent  upon an  insufficient supply or
 total  absence of oxygen in  the  inspired
air, we have  many examples.
   It has been before remarked, that ex-
tremely  rarefied  air, and various  gases,
which are not of  themselves positively
deleterious, may become negatively so;—
or, in other words, they may destroy, not
in consequence of their being possessed
of any noxious property, but because they
do not furnish the oxygen, which is indis-
pensable  to  hematosis.    Hydrogen and
azote are in this category.  If  an animal
be  placed  in either of these gases, it
breathes  for  a  minute perhaps;  but the
conversion  from venous  to arterial blood
in the lungs  being prevented, arrest  of
the circulation, in  the  radicles  of the
pulmonary veins, occurs, in the same man-
ner as in other cases of complete asphyxia.
We can  hardly,  however,  imagine  the
case, in which asphyxia from exposure to
these  gases could  happen to man.   The
same may be  said of an extremely rarefied
atmosphere.   For the purposes of experi-
ment  we occasionally place one of the
lower animals under the receiver of the
air-pump, and rapidly exhaust the air: the
effect is here speedy,  if the vacuum be
suddenly formed, and the pathology of as-
phyxia,  thus induced,  is like the forms
which we have just considered; but if the
rarefaction be made more  gradually, as-
phyxia is  longer  in being  produced, and
the phenomena are much more equivocal.
  In  the respiration of animals, the oxy-
genous portion  of the air is more or less
consumed, and carbonic acid, of a nearly
equal volume, takes its place.  In other
words, the vital portion of the air is ab-
stracted, and an equal volume of air, which
is altogether irrespirable, is added to the
azote—which, as we have  seen, is itself
negatively injurious.  Now, if an animal
be  confined in a restricted  quantity of at-
mospheric air, it can exist so long  as there
is oxygen  enough for due  hematosis, and
so long as the deadly agencies of  the car-
bonic acid and the azote are not powerful
enough  to destroy.  The  bad effects of
confined air might therefore, be  mainly,
if not wholly, ascribed to the presence of
an  undue quantity of carbonic acid, and to
the uncombined azote, left after the disap-
pearance of the oxygen.   This, at least,
is one view of the matter;  but those phy-
siologists, who believe that the air  is taken
into the pulmonary vessels  without de-
composition; that its oxygen disappears
in the course of the circulation, and that
carbonic acid is formed in the system, and
merely  given off at the lungs,—a  view
which appears  to be the most in accord-
ance  with observed facts,—would ascribe
the phenomena to the deleterious agency
of the carbonic acid.
  Instances  have  occasionally occurred,
where death has been caused in this way,
—as  in a diving-bell, where the air could
not be renewed; but the most melancholy
example on record was in the—since cele-
brated—' Black Hole' at Calcutta—a place
of confinement 18 feet by  18, or  contain-
ing 324 square feet, in which one hundred
and forty-six persons were  shut up, when
Fort William was taken, in 1756, by Su-
rajah Dowla, Nabob of Bengal.  The room
allowed to  each  person a space of 26£
inches by  12 inches, which was just suffi-
cient to hold them without pressing vio-
lently on  each other.   To this dungeon
there was  but one small grated window,
and the weather being  very  sultry, the
air within could neither circulate nor be
changed.   In less than an  hour, many of
the prisoners were attacked with extreme
difficulty of breathing;  several were de-
lirious, and the place was filled with in- 
490
ASPHYXIA.  (From Irrespirable Gases.)
coherent ravings, in which the cry  for
water was predominant This was handed
to them by the sentinels,  but without the
effect of allaying their thirst In less than
four hours, many were suffocated, or died
in violent delirium.  In an hour more, the
survivors, except those at the grate, were
frantic and outrageous.   At length, most
of them  became insensible; and, eleven
hours from the time they were imprison-
ed, of the  one hundred and forty-six that
entered, twenty-three only came out alive,
and these were in a highly putrid fever,—
from which, however, by fresh  air,  and
proper attention, they gradually recover-
ed.  A similar instance happened in Lon-
don, in 1742. Twenty persons were forced
into a part of Saint Martin's round-house,
called  ' the Hole,' during  the  night,  and
several died.
   In these, and  in  all similar cases, the
lethiferous influence is doubtless of a com-
pound  character; being  dependent both
upon diminution of  oxygen, the presence
of uncombined azote,  and of an unusual
quantity of  carbonic  acid.   This acid,
which, as  we have  seen,  is given off in
respiration, is heavier than atmospheric
air, and  consequently accumulates near
the ground, where ventilation  is imprac-
ticable or  neglected, and  it can thus be
readily understood,  that where the only
aperture into the chamber is by the roof,
or by a window high  above the ground,
the lower strata of air may become irre-
spirable for some time before the upper.
   3. The gases which produce death by
occasioning a  spasmodic  closure of the
glottis,  or  which  are irrespirable,  are
not many.   They are the carbonic acid,
ammoniacal gas, muriatic acid gas, deut-
oxide  of azote,  nitrous  acid  gas,  and
chlorine.    We  have  before   observed,
that different  writers have classed  un-
der this  head, oxygen, the  protoxide  of
azote, carburetted hydrogen,  carbonic ox-
ide, sulphuretted hydrogen,  and arsenu-
retted  hydrogen ; but these gases give
rise to no symptoms  resembling asphyxia.
They are positively deleterious, and act
upon the frame as poisons,  under  which
head they will be considered.
  A similar remark might, indeed, be ex-
tended to  the gases enumerated as pro-
ducing asphyxia by spasmodic  closure of
the glottis, when their strength is reduced
below a  certain point  Above this, con-
traction of the muscles that close  the glot-
tis is produced, as soon as the  gas  comes
in contact with them; but if sufficiently
diluted, they may pass  into the  lungs, and
exert upon those organs, and through them
on the organism, the peculiar effects which
they are capable of inducing.  Thus, car-
bonic acid may cause symptoms of nar-
cotism,  whilst  the ammoniacal  gas,  the
muriatic acid, the deutoxide of azote, the
nitrous  acid  gas, and  chlorine, may pro-
duce  violent irritation, and inflammation
of the air passages.   It is, however,  in
their  relations  to  asphyxia  that we have
to consider them at present.
   Carbonic acid gas is by  no means an
uncommon cause of asphyxia, and it  has
not unfrequently proved fatal more slowly
by  the  poisonous  narcosis  which it in-
duces.  Sir Humphry Davy  found,  that
air was still irrespirable,  when it  con-
tained three-fifths  of  its  volume of car-
bonic acid.
  This  gas  accumulates  wherever com-
bustion  is going on; but it is the accumu-
lation from  brasiers  of charcoal,  where
ventilation is impeded, that has been most
lethiferous.   The  Journals contain  ac-
counts of many persons who have perished
during the night from this cause;  and it
was the method  adopted  by the younger
Berthollet to rid himself of a disagree-
able  existence,  in which he  succeeded.
In crowded apartments, artificially heated
and well lighted, inconvenience,—such as
hurried  respiration and circulation, giddi-
ness,  &c.—are not  unfrequently experi-
enced from the presence of this  gas, and
allusion has  already been made  to its be-
ing concerned  in the fatal affair of the
Black Hole.  It is the fixed air given off
during  the vinous fermentation; and,  in
the large vats of extensive ale and porter
breweries, sufficient of the gas is often
contained  at the bottom to destroy those
who may venture down.   It  is usual to
pass a  lighted  candle  to t\\e  bottom, and
if it continues  to  burn, the descent  may
be made with safety,—carbonic  acid  not
supporting combustion. In like manner,
it is met with in deep wells, and  the same
plan  is  adopted to discover whether  the
air will  allow of combustion and respira-
tion;  but many a  labourer has fallen a
victim to his want of attention to this pre-
cautionary measure.   This air  likewise
constitutes the  choke-damp of  the  coal
mines,  in  contradistinction to  the fire-
damp, which consists  of carburetted hy-
drogen.   It  issues  in  some volcanic re-
gions in great quantities, from fissures in
the rocks,  and is  found in caverns, as at
Pyrmont in Westphalia, and at  the cele-
brated Grotto del Cane at Naples, so called
in consequence  of the number of dogs that
are asphyxied  in  this collection of irre-
spirable gas.  Carbonic acid is also extri- 
ASPHYXIA. (From Irrespirable Gases.)                 491
cated in  considerable quantity in lime-
kilns, by the agency of heat which drives
it off from the limestone or carbonate of
lime,—and the public prints have detailed
many cases in which life has been lost
owing to the  poor  benighted traveller
having  laid himself down to  rest  in the
warm but destructive atmosphere around
one  of these furnaces.
   Lastly.—Plants evolve carbonic acid in
the night, which renders the  air  of con-
fined apartments  unwholesome, and, in
some cases,  induces asphyxia.  An in-
stance of this kind is cited from the pub-
lic prints by Dr. Paris.  (Paris and Fon-
blanque. Med. Jurisprudence, II. 49.) A
gentleman,  having  frequently had  his
pinery robbed, the gardener determined to
sit up and watch.  He accordingly posted
 himself with a loaded fowling-piece in the
green-house, where, it is presumed, he fell
asleep, and in the morning was found dead
 upon the ground, with every  appearance
of suffocation, supposed to have been occa-
sioned by the disengagement of ' mephitic
gas' from the plants  during the night
   Carbonic acid cannot be breathed in a
 pure state, or even, as we have seen, when
diluted  with  two-fifths of its  bulk of at-
 mospheric air.  It occasions an immediate
 spasmodic  closure  of the glottis,  which
 cannot be overcome by the strongest ef-
forts, preceded by painful irritation of the
glottis and the upper parts  of the throat
 When, therefore, a person  descends into
a brewer's vat a foul well, &c., in which
 the gas is in a concentrated state,  he dies
as speedily from suffocation,  as when a
ligature  is put  round the neck so as to
completely shut  off the  entrance of air
into the lungs.
   With  regard to the discrimination  of
asphyxia produced by the  inhalation  of
carbonic acid,  nothing can guide us ex-
cept the history of the event,  which may
be deduced from the circumstances sur-
rounding the  individual,—not from any
intrinsic evidences.   Pathological  anato-
my,  independently of circumstantial evi-
dence, does not indicate  any phenomena,
which distinctly show, that death has re-
sulted from this variety of asphyxia rather
than from any other.
   In the treatment of asphyxia from the
respiration of carbonic acid, the first im-
portant  procedure  is to withdraw the pa-
tient from the deleterious atmosphere, and
strip him of his clothes,  in order that the
air may come freely in  contact with his
skin.  He must then be  exposed to cool
air, and  cold water  be thrown upon his
face, until the respiratory movements re-
appear.  The  reasons for  this  plan of
management have been given previously.
Friction over the chest must also be  em-
ployed, and ammonia  may be held to the
nostrils,  so  as to stimulate the oppressed
energies.  These are  the most important
steps;  but  in addition, insufflation  has
been advised to remove the noxious gas
from the lungs, and to re-excite respira-
tion ; and Galvano-puncture, in the mode
recommended by Leroy d'Etioles, for sti-
mulating the diaphragm  to contraction.
It has been conceived,  too,  that the insuf-
flation  of oxygen might be serviceable;
and,  by some, blood-letting has been  em-
ployed ;  but it  is not easy to discover the
rationale of the action of  these agents.
The judgment of the practitioner must
suggest  to  him, whether these or other
means, adapted to particular emergencies,
may be indicated.

  Bibliography. — Portal, (A.)  Observations
sur les effets des vapeurs mipkitiques sur le corps
de Vhomme, et sur les moyens de rappeler a la vie
ceux qui ont iti suffoqvis.  Paris, 1775, and  1805.
12mo.
  Nicolas, (P. F.)  Dissertatio de variis vapori-
bus mephilicis, et novo quo  suffocati ad vitam revo-
centur auxUio. Nancy, 178L  4to.

  The  ammoniacal gas, as well as the
muriatic acid gas, the  deutoxide of azote,
nitrous acid gas, and  chlorine—when in
a state of concentration—are so acrid, that
when inhaled,  the  most violent irritation
of the  air  passages is induced.  It has
generally been conceived, that they prove
fatal by occasioning spasmodic closure of
the glottis,  but, from  some experiments
made by Mr. Broughton  (Journal of the
Royal  Institution,  Vol. I.  for 1830.),  it
would  seem, that certain of them  pass
the rima glottidis  in  sufficient quantity
to produce phenomena, which are appa-
rent on dissection.  In some experiments,
which  he made on the  effects  of chlorine
on several mice, he found,  that they fell
dead in  less than  thirty seconds, and, on
opening them, the lungs were found tinged
with the yellow colour of the gas, and the
peculiar odour of chlorine was perceptible
throughout their structure.
  Still, it  is probable, that death  arises
from asphyxia, not from the poisonous in-
fluence of the gas, the effects  of which
could scarcely be exhibited in so short a
space as thirty seconds.
  The smell of these  agents will enable
us to judge—in the absence of any  his-
tory of the case—as to the cause of the
asphyxia.
  The treatment  is similar to that for as-
phyxia by carbonic  acid gas; and, in ad- 
492
ASPHYXIA.  (From Submersion.)
dition, insufflation with sulphuretted hy-
drogen  gas—largely diluted  with  com-
mon air—may be advantageously had re-
course to.
  As these gases are extremely irritating,
there may be a greater necessity for the
employment  of blood-letting, in asphyxia
induced by them.
  4.  But the most interesting varieties
of asphyxia are those that are owing to
some mechanical cause preventing the en-
trance  of air into the  lungs.   Some of
these we shall consider  in detail.
  a. Asphyxia by submersion or drown-
ing is perhaps  the most  common, and
one of the  most interesting in the phe-
nomena which it  presents.  It differs ac-
cording as  the  submersion is complete
from the first  or the  person has  risen
again  and again to the surface.  In the
former  case, we should expect the  post
mortem appearances to be unequivocal.
When  a person  falls into water,  and re-
mains  beneath  the surface, an effort  is
made to inspire; but this is impracticable,
in consequence of the medium  being irre-
spirable.  Water is, however, drawn in,
but as  soon  as the fluid reaches the glot-
tis,  the muscles which close  it contract
spasmodically; little or no  water can en-
ter, and death takes place  with the same
phenomena as present themselves in stran-
gulation.  These, as we have before shown,
are,—accumulation of blood in  the pulmo-
nary artery  and right  side of the heart,
owing to the nonconversion of venous into
arterial blood, and more or less vacuity in
the pulmonary veins, and left side of the
heart.  Yet Dr. Roget  (Art. Asphyxia, in
 Cyclopadia  of Pract.  Med.)  strangely
enough affirms,  that where there  is no
struggle, the lungs will be but little dis-
tended, and will preserve their natural
colour, and that there will  be no great ir-
regularity in the comparative quantities
of  blood  contained in the arteries and
 veins.  His description  applies  sufficiently
 well to those cases  in which considerable
struggling precedes death,  whilst his nar-
ration of  the appearances met  with under
the latter circumstances, might be  trans-
ferred, with much propriety,  to asphyxia
from submersion where there has been no
 struggling.
   It is an important question  of forensic
 medicine,—whether there are  any intrin-
 sic appearances about the found drowned,
 which can  enable us—in the absence of
 all history of the case—to  pronounce de-
 finitively, that death has  taken place by
 drowning.
    It has often been  affirmed, that the pre-
sence of water, or, at all events, of frothy
mucus,  in the bronchial tubes, is charac-
teristic  of this variety of asphyxia.  But
dissidence  has  existed on  this  point
amongst observers.  At one time, the en-
trance of water into the bronchi was con-
sidered  to be the essential cause of death
but it is now sufficiently established, both
by  experiments  on animals, and  by ob-
servation  of the  bodies of the drowned,
that but little water is to be looked for ;—
generally, indeed, there is none; but there
may be  a small quantity of frothy mucus,
totally  insufficient, however,  to account
for  death.   Wepfer,  Conrad,  Becker,
Waldschmidt,   Littre,   Petit,  and
others,  have never met with water in the
air  tubes;  and Morgagni, Haller, Ev-
ers, Desgranges, and others, assert, that,
in their examination  of several  drowned
persons, they have neither found water
nor froth, although in  other cases, some
of these observers have met with both one
and the other.  Louis  instituted several
experiments  with the view of testing this
matter.   On  immersing animals  in co-
loured liquids, he discovered them  in the
trachea, and sometimes even  in the last
bronchial ramifications.  His experiments
were repeated by Goodwyn, both for the
purpose of proving that water positively
enters  the trachea, and of dispelling an
idea, which had been entertained, that the
frothy mucus is nothing more than a se-
cretion  from the bronchial tubes, owing to
extreme engorgement  of the pulmonary
artery, during the last struggles of the in-
dividual.  Three animals were immersed
in mercury, and after death an appreciable
quantity of the metal  was found in the air
passages.   Experiments by Berger, Or-
fila, Piorry, and others, have led to simi-
lar results.
  Admitting, then, that a small quantity
of water  may enter the bronchial tubes,
we can readily understand, that if the in-
dividual were to rise  to the surface and
attempt to  breathe, the inspired air, be-
coming mixed with the water and mucus
of the  bronchial  tubes, might communi-
cate the characters assigned to this frothy
mucus; but  it is not quite so easy to un-
derstand that any frothy mucus or liquid
should  be met with in the drowned unless
under these  conditions.  If the individual,
after immersion  took in any fluid and re-
mained beneath  the  surface,  or, in other
words,  did not inspire afterwards,  it could
scarcely be frothy.  This would appear  to
be  the view  embraced by Orfila.  He  is
of  opinion, that  a  greater or less quan-
tity of water is generally drawn in during 
ASPHYXIA.  (From Submersion.)
493
the agony of drowning,  and that the ex-
istence of froth  in the  bronchi depends,
in a great measure, on  the  circumstance
of the animal's having  risen to the sur-
face, and respired air once or twice pre-
vious  to  its  final  submersion.  It  need
scarcely be added, that  whenever froth is
met with in the air passages, it is a proof,
that the individual was immersed alive,—
respiration being indispensable to mix the
ah* with the liquid.  The fact,  however,
of water being met with in the tubes is
not a sufficient proof that the person came
to his death by drowning.  Messrs. Cox
and Evers  affirm, that if cats be first
strangled, and then thrown into  water,
and suffered to remain there for 12 or 14
minutes,  no water will be  found  in the
lungs, except when the  abdomen is com-
pressed.  In the latter  case, the air and
mucus being driven from the lungs, the
 iiquid will be able to enter.  Messrs. Or-
fila and Piorry have deduced,  however,
from their experiments, that in  the case
of dogs, killed by strangulation, and im-
mersed in water a short time after death,
water constantly enters  the trachea, and
may pass even to the last bronchial rami-
fication, if the animal be kept in a verti-
cal position, with the head  upwards,—in
other words, as if it had died from drown-
ing.   Hence, it may be  inferred, that the
entrance of water into the air passage, is
not necessarily a vital act.  Its  presence
 in the trachea, bronchi, and even in the
ultimate  subdivisions  of the  bronchial
tubes, is not a certain sign, that the per-
son was living at the time of immersion,
even if it should be shown, that the liquid
is of the same nature as that in which he
is found drowned.  Still, as M. Devergie
has remarked, this conclusion is not en-
tirely rigorous, unless we infer, that the
same results occur on man as on dogs.
  Again,—it has been affirmed, that the
presence of the  frothy  mucus  is not of
itself  positive evidence of death from sub-
mersion,  and that it has been observed in
other kinds of death.  Orfila says, it is
not necessary that water should enter the
trachea, in  order  that  this frothy  fluid
should be found;  and  that the trachea of
those who have been hanged always con-
tains some  of it.   The  first of these as-
sertions has been confirmed by  daily ob-
servation;  but Devergie—although he
does not deny the latter—asserts, that he
has opened the bodies of thirteen  indivi-
duals, who had been hanged, and that in
none did he meet with frothy mucus m
the trachea.   He suggests, moreover, that
it is important to  have correct ideas re-
  vol. n.          42
specting the nature of this froth, in order
that it may not be confounded with frothy
sputa.  The froth of the drowned, he says,
is commonly white, with very minute and
numerous bubbles of air,  constituting a
foam (mousse) rather than a froth (ecume).
It never adheres  to the trachea by the
mucus, but is applied immediately to the
tube.   The same slightly viscid water, of
which it is formed, attaches it to the tra-
chea:  all the bubbles  that  constitute  it
have  a very fine aqueous envelope; they
are readily divisible, and often, when the
trachea is  opened, the greater part sub-
side like soap-bubbles.  Whence, he con-
cludes, the frothy water of the drowned
has but little similitude  to  the sputa—
either of pneumonia  or of catarrh—and
that attentive  observation  will prevent
them from being confounded.
  From all, then, that has been said,  it is
manifest, that although our knowledge on
this matter needs some of that certainty,
which  is so desirable, the  presence of
frothy water, or of frothy mucus, does not
perhaps afford us any unquestionable  evi-
dence that death has taken place  from
drowning rather than from any other form
of asphyxia.  Devergie is of opinion, that
the strongest of the presumptive signs of
drowning is the existence of a non-mucous
froth  or foam on the internal membrane
of the trachea—itself in a sound state.
  Again;—it  was at one  time thought,
that the stomach would be found largely
distended with  fluid  in cases  of death
from drowning; but this also  is erroneous.
Perhaps in all cases, some  fluid will be
swallowed, whilst the power of degluti-
tion remains; but the convulsive action,
induced in the muscles of the throat will
generally prevent  much  from  passing.
After death, it does not make its way into
the stomach.  The  presence, therefore,
of the fluid of immersion in that organ
would be evidence,  that the person  had
been  thrown in alive; but the evidence
loses much of its value, from  the difficulty
there must always be  in establishing the
identity between the fluid in  the stomach,
and that into which  the body  had  been
cast.
  All these are interesting topics of me-
dico-legal inquiry, which will be farther
developed under another head. (See Death,
apparent.)
  A fluid state of the blood has been con-
sidered, by almost all writers on this sub-
ject as an evidence of death from drown-
ing.  It would be a singular circumstance
were this the fact;—unaccountable, indeed,
unless we were to consider, that the fluid 
494                    ASPH\a±a.  {from Submersion.)
of immersion were to penetrate the tis-
sues to mix with one  of its solutions, and
we know the avidity with which water
will penetrate  animal membranes to ac-
complish this.  In canvassing  this point
Devergie  states properly, that the exist-
ence of coagula  in  the  vessels of the
drowned is very uncommon, and  that the
fluidity of  the blood  is  such, that it flows
like water,—but  he  judiciously  adds,—
this fluidity ought to be common  in  cases
of sudden death;  and he says, that he has
found  it so in  a number of persons, who
had destroyed themselves otherwise than
by submersion.  Such,  also, has been the
result of the observations  we have made
on the subject.
   Of the  general impracticability of re-
suscitation in cases of asphyxia by drown-
ing—where  the causes have  been fully
and effectively applied—even a few min-
utes after the cessation  of  respiration,
mention has already been  made (p. 470.),
when treating of asphyxia in general. Al-
lusion  was also  made  to  fabulous narra-
tions of restoration  after  a long immer-
sion.   It is but too true, however, that an
immersion of a  few minutes only will
often 6eal  the fate of the sufferer.  It has
been asserted,  that if the submersion has
not exceeded  five minutes, and no blow
against a stone, or other violence, has oc-
curred to complicate the effects, the efforts
at resuscitation, if properly conducted, will
generally  be successful.   After a quarter
of an hour, recovery is not very common;
after twenty minutes, or half  an hour,  it
 may be considered hopeless. The longest
 period  recorded  in  the  Reports  of  the
 Royal  Humane Society is  three quarters
 of an hour;  and from  the first report  of
 the  establishment  for the recovery  of
 drowned  persons in Paris, it would ap-
 pear, that out  of 23 cases restored to life,
 one had been three quarters  of an hour
 under  water; four,  half an  hour; and
 three, a quarter of an hour; the rest for a
 much shorter time. (Roget. Loc. Cit.)
   Perhaps the safest  rule is to attempt
 resuscitation, unless the signs which char-
acterize the existence of Death (q. v.) are
present—according  to some,  unless  pu-
trefaction, or cadaveric rigidity, has su-
pervened; but the  humane practitioner
requires no guide of this sort.   He must
 judge according to his best powers of dis-
 crimination,  whether the  case is one  of
 asphyxia, or of permanent  privation of vi-
 tality,  and if  any doubt remains on his
 mind, his  efforts must  be  continued until
 the doubt  is removed.
   As regards  the treatment of this form
of asphyxia, much  need not be  said,  in
consequence of the immediate application
which the remarks made on the general
treatment of  asphyxia have to  this va-
riety.  The rules to be adopted may  be
summarily expressed as follows:—
   When the body is taken  from the wa-
ter,  the  mouth  and  nostrils  should  be
cleansed,  and  if frothy mucus exist in the
fauces it  may be removed  by  the finger
enveloped in  a handkerchief.   The wet
clothes should be removed; the  body  be
wiped dry, and be wrapped in a dry blan-
ket : in this way it can be taken to the
nearest habitation, on a board, or in a cart
When the body has been  conveyed  to a
room, admitting of a good fire,  if the wa-
ter has been colder than the medium  tem-
perature of the climate, it may be stripped,
placed upon  a sofa, table,  or on a board
supported  on  chairs,  before the fire,  at
such a distance, that the radiant heat  does
not act too  powerfully upon it;  whilst
the air of the  apartment  is  not above
75° or 80°. (Kay.  p. 52.)  A greater de-
gree  of heat than this is noxious, for rea-
sons  before mentioned; and it has been
properly  observed, that  great  caution
should be used in the application of an
elevated temperature to even a part of the
body,  excepting  to the extremities—and
they ought not perhaps to be excepted—
lest the vital power of some important or-
gan should be thereby enfeebled.
   Such is the course,  as regards the ap-
plication  of  warmth  to the body, most
commonly pursued; yet as we have pre-
viously seen, it has been a matter of ques-
tion with some, whether the temperature
of the body should not be kept depressed
even when that of the atmosphere is low,
until respiration has been restored by in-
sufflation. Whatever doubts may exist  on
this point there can be none, that any un-
due elevation of temperature is positively
injurious,  and that temperature, as Dr.
Kay  has  observed,  must be regarded  as
exerting  chiefly a conservative influence.
   As  soon as the body has been placed in
the favourable circumstances mentioned,
attempts  must be made to re-excite  re-
spiration, during which the head and chest
should be kept raised, and the nostrils and
mouth cleansed and open.
   From what has been before said, the  ra-
tionale of the following recommendations
will be obvious.  Let the individual be so
exposed, that  the atmosphere can act on
the body; employ  friction; and  artificial
respiration according  to the plane previ-
ously advised, by means of the bandage,
and the instrument of Leroy or any other 
ASPHYXIA.  (From Strangulation.)                   495
at hand, with the  precautions  that  have
been pointed out, lest serious mischief be
done to the delicate fabric of the lungs.
   Whilst artificial  respiration  is carried
on, and especially if there be signs of re-
turning animation, the warmth  of the pa-
tient may be somewhat increased, and bot-
tles  of warm water, or  warm  bricks or
warm flannels, may be applied to the feet,
knees,  armpits,  pit of the stomach,  and
along the spine.  The warmth of a healthy
person  lying by the body is said, in the
Report of the Royal Humane Societv, to
have been found, in  some cases  of aaults,
but particularly of children, very effica-
cious.   In the same report  it is affirmed,
that the warm bath, where it can be pro-
cured, is preferable  to all other means of
communicating heat; but  the obvious ob-
 jection to it is, that  free  exposure to the
air is  prevented, whilst the experiments
of Edwards have established, that water
exerts an injurious influence on the nerv-
ous and muscular systems.
   As respects the use of stimulants, blood-
letting, and other agents—often  had re-
course to in this and in other forms of as-
phyxia—what has been already observed,
 when  touching  on  the  treatment of as-
phyxia in  general,  is sufficient,  and the
same may be  said of the means that are
necessary after recovery.
   It need scarcely be remarked, that the
absurd practice of hanging up the drown-
 ed by the heels when first  taken out of
the water,  and of rolling them on casks,
ought to be universally reprobated.  They
 were introduced at a period when death
from drowning was  supposed to be owing
to the  entrance  of water  into the chest
and abdomen.  If, in the  language of the
motto adopted by the Royal Humane So-
ciety, " lateat scintillula forsan"—the fee-
ble spark could scarcely fail to be extin-
guished by such treatment.

   Bibliography. — Faisolle de Champeaux.
Expiriences  et observations sur les  causes de la
mort des noyis.  Lyon, 1768.   8vo.
   Pia.  Dilad des succis de  V etablissemet  que la
ville de Paris a fait en faveur des noyis.   Paris,
1774.  3 vols. 12mo.
   Mendel, (L.)   Nouvelles  recherches sur les
noyis, les suffoquis par les vapeurs  mephitiques,
et sur les enfans qui paroissent morts en venanl au
monde.   Paris, 1776.
  Testa, (A. J.) Delia morte apparente degli an-
negali.  Firenz, 1780.   8vo.
  Lecter, (J. Ph.)  Dissertatio de asphyxia aqiiis
submersorum, theorelice  et practice illustrata. Go't-
tin?. 1785.  4to.
  Goodwyn, (E.) Dissertalio de morbo morte que
submersorum invesligandis.   Edinb. 1786.   8vo.
  Metzger, (J. Dan.)   Ep. gr. sistens animad-
versiones nonnullas in novam Goodwinnde. morte
tubmersorum hypothesin. Korugsberg, 178b. 4to.
  Desg ranges.  Mimoire sur les moyens de per-
fectionner Vilablisscment public formi d Lyon en
faveur des noyis. Lyon, 1790. 8vo.
  Berger, (J. F.)  Essai physiologique  sur la
cause de Vasphyxie par submersion.  Paris.   4to.
An. XIII.
  Marc  Des moyens de constaler la mort  par
submersion, mimoire a la suite du manuel aau-
topsie, par Rose.  Paris, 1808.
  Cailleau, (J. M.)  Mimoire sur Vasphyxie par
submersion.  Bordeaux, 1799.
  ------ Notes rilalives a. Vilablissement en fa-
veur des  noyis dans la ville de Bordeaux.  1806.
8vo.
  Mann i, (P.)   Del  Irallamento degli anneeati.
Pesaro, 1826.  8vo.

  b. The phenomena of death from hang-
ing and strangling are identical, so far as
regards the intrinsic evidences.   The  ex-
trinsic  differ  somewhat,  in consequence
of the situation of the cord, which, in  the
latter case is  horizontal;  in the former,
more vertical.   It can be understood, too,
that in  the former there  may be disloca-
tion of the cervical vertebras, whilst in the
latter this  is not to be expected; but more
mischief may be  observable in the  rings
of the trachea, owing to the violence with
which the rope is tightened with the view
of rendering death certain; for strangula-
tion is prima facie evidence of homicide;
hanging, of suicide,—it not being a very
easy matter to hang a person against his
will.  Occasionally, too, strangulation  has
been effected by putting a stone or a coal
in  a  handkerchief, and tightening  it so
that  the  coal may press  upon  and  ob-
struct the wind-pipe; and cases have  oc-
curred  of  manual  strangulation,  the  evi-
dences of Which have been apparent in the
ecchymosis produced wherever the points
of  the  fingers have  pressed.  All these
varieties,  as well as  the  mode  of discri-
minating between them, will be canvassed
under an appropriate head. (See Death.)
   It is  obvious, that the intrinsic pheno-
mena must differ in these cases, according
as the ligature is effectually or imperfectly
applied; and, again, a difference may ex-
ist  as regards the ratio moriendi,—whe-
ther, for example,  death has begun in the
lungs, or whether, owing  to the disloca-
tion of the vertebra  and consequent in-
jury to  the spinal marrow, the  organs of
innervation have been the first  to be  de-
prived of  vitality. (See Death.)
  Now, as injury to the  spinal marrow
could not  be easily induced  in death by
strangulation,  this must be esteemed as
the more simple form of the two.
   Of old,  the  idea generally entertained,
was,  that  death  in strangulation  was
caused by the cord pressing on the jugular
veins, and thus interrupting the return of 
496                   ASPHYXIA.  (From Strangulation.)
blood from the encephalon, whilst its trans-
mission to  the  brain by the vertebral ar-
teries was  uninterrupted.  Engorgement
of the  cerebral vessels consequently su-
pervened, and apoplexy.  The striking ob-
jections  to  this view  were,—that these
very vessels  may be tied without produc-
ing  fatal apoplexy  or apoplexy  at  all.
Even  the  vertebral arteries  have  been
tied, along with the jugulars and carotids,
on animate,—and yet they have survived
the operation.  In some experiments, in
which Dr. Kay included both the  carotid
and  vertebral arteries  in  ligatures,  one
or two of the animals recovered, although
they  were  exceedingly weak for some
time after the operation. (Op. Cit. p. 284.)
Again,—Dr. Kellie tied the common ju-
gular and  the  recurrent veins low down
in the neck on  two dogs, one of which ap-
peared to  suffer no inconvenience; the
other,  although rather dull and heavy for
two days, speedily recovered. (Edinburgh
Med.-Chirurg. Trans. I. 162.)
   Another  strong objection is the well-
known experiment  of Dr. Monro, senr.,
who suspended a dog after having made
an opening into its trachea below the place
where  the  cord encircled the animal's
neck.   Through  this  aperture the  dog
breathed freely during the  period of sus-
pension, which was three  quarters of an
hour.  He  was then  cut  down, and did
not  appear to  have  sustained any serious
injury.  When,  however,  the cord  was
placed below the orifice, and  the  suspen-
sion was renewed, he soon died. (Curry.
Popular Observations, &c. p. 71.)
   The works  on medical jurisprudence
refer  to cases, in which  attempts  have
been made to save the lives of criminals,
by making an opening into the trachea.
 (Mahon, Medecine legale, &c.  III. 62.
 Fodere, Traite de Med. leg., &c.  II. 521.
 &c. &c.)  A well-known case of this kind
 is that of Gordon, who, at  the commence-
 ment  of the last century, was sentenced
 to be  hanged  for highway robbery.  He
had become very rich by his avocation,
and offered a large bribe to induce a young
 surgeon to attempt to defraud the law of
 its victim.   An incision was  made in his
neck,  and a tube was introduced through
it into the trachea, in  such a manner, that
respiration might go on, if the upper part
of the neck were constricted by the cord.
 The man  was, however, very heavy, and
 it was considered,  that other accidents,
 besides the mere interruption of  respira-
 tion, were produced by the fall, for  when
the body had been suspended the accus-
 tomed time, and was cut down, and hand-
ed over to the friends, tlie surgeon drew
blood from the jugular vein, and used the
utmost exertion to resuscitate him, but in
vain.  Some slight evidence  of  vitality
was manifested.   Once he  opened his
eyes and sighed; but this was all.
  Moreover, it is by no means proved, that
any kind of congestion of the encephalon
occurs in death from strangulation or hang-
ing.  The affirmative view has doubtless
been embraced, chiefly in consequence of
the marked turgescence of the vessels of
the  integuments of the head and face.
After death from hanging and strangula-
tion, the vessels of the scalp, and of the
integuments of the  head and  neck, are
gorged with blood, as well as tiiose of the
mucous membranes  of the eyes,  nostrils,
and lips,  and  not unfrequently blood ex-
udes from  the  nose and  mouth.  From
these outward signs of polyremia, it was
inferred, that similar engorgement of the
encephalon existed; but, although Mor-
gagni, De Haen, and others, directed their
attention for a iong time to the  subject,
they did not discover any signs of en-
gorgement  in the brains of such as had
died by suspension;  and the  observations
of Coleman on  animals,  and of Monro
and Kellie on  the  bodies of criminals,
who had died on the gallows, confirm their
assertions.  Neither is there any appear-
ance of congestion  in animals that are
killed after a ligature has been put on
both the internal jugular veins,  or when
these vessels have been obliterated by the
pressure  of tumours.
   Taking all these facts,  then, into con-
sideration, we are justified, we think,  in
inferring, that the ligature of the vessels
of  the neck does not occasion immediate
death, and that the constriction by  the
cord, in suspension and strangulation, does
not produce engorgement of the vessels
of  the brain.  We have, therefore, to look
for another chief cause of death.  This is,
doubtless, as had been  occasionally sug-
gested (Belloc,  Cours de Med. leg. p.
199.), and has recently been much insisted
upon by  Dr. Kay (Op. Cit.  p. 288.),  the
 interruption of respiration.
   The duration of life, in these cases, may
be  modified, as has been already suggest-
 ed, by various  circumstances,—such  as
 the mode in which the rope is fixed; the
 height from which the body  has to fall;
 &c.  A  humane executioner can expedite
death by adding his weight to that of the
 criminal, so as to luxate the  vertebra? of
 the neck;  and  Louis found, that the Pa-
 risian executioner could generally occa-
 sion death without a struggle,  by rup- 
ASPHYXIA.  (From Strangulation.)
497
turing the ligaments which unite the first
and second  vertebra?,  or  the ligament
which confines  the processus dentatus  of
the latter, so as to occasion pressure  on
the spinal cord.
  It may be laid down as a general rule,
that death will  supervene in a longer or
shorter period, according as the oblitera-
tion of the air  passages  is  more or less
complete. Sometimes, as already remark-
ed, the  rope may be placed between the
lower jaw and the larynx, or in such a po-
sition, that a small supply of air may en-
ter the lungs;  or unusual rigidity of the
cartilages of the  larynx  may exist so as
to permit air to enter—if not in sufficient
quantity  to maintain life, at all events to
prolong the sufferings.   This is often the
case with those who  attempt to destroy
themselves.
   The interruption, therefore, to respira-
tion, must be regarded  as the  chief cause
of death from suspension; yet as Dr. Kay
has observed, the  condition of the sangui-
ferous system is considerably modified in
this form of asphyxia, and the circulation
in  the brain is  somewhat affected, though
congestion may  not  be induced.   The
sphincters  are frequently  relaxed;  the
urine and fieces consequently escape, and
there is  often erection of the penis with
emission of semen.  The cause of these
different symptoms has been a topic of  in-
quiry.   Orfila attributes the last symp-
tom to traction of the spinal cord, conse-
quent on the extension of the ligaments
of  the vertebral articulations; and in sup-
port of the  opinion, he affirms, that erec-
tion is  a frequent  consequence of trau-
matic affections of the cord:  he cites, also,
a case in which it occurred in consequence
of  luxation of the fifth cervical vertebra.
Dr. Kay—and we suppose every phreno-
logist will join with him—is  inclined  to
attribute it  to some vascular disturbance
of  the cerebellum.
   In some animals, the ligaments  of the
spine can be readily stretched so  as  to
cause death.  Every cook knows that this
is the case with the rabbit—and  we may
readily conceive, with Orfila, that death
might be produced  in  this  way in man

  We have before referred to some  of the
accidents, that occasionally complicate  as-
phyxia by suspension;—the injury  to the
larynx, fee.   There have also been cases
in which true apoplexy has occurred,—et-
fusion of blood having taken place on the
brain; but  these  appearances  present
themselves in a few instances.only.  L\hey
are by no means to be looked for m simple
                  42*
cases of asphyxia  from hanging or stran-
gulation.
  In  a  manuscript note, furnished by Sir
Benjamin Brodie to Dr. Paris (Med. Ju-
risprudence, II. 44.),  it is stated  as  the
opinion  of that distinguished surgeon, that
if an animal should recover from the di-
rect consequence of strangulation, it may
probably suffer from the effects of the liga-
ture on the nerves afterwards.  Sir Ben-
jamin passed a ligature around the trachea
of a Guinea-pig, and tied it firmly on the
back of the neck with a knot: the animal
was uneasy, but nevertheless breathed and
moved about:  at the end of fifteen min-
utes, the  ligature was  removed;  but on
the  following morning the animal died.
On dissection,  no  preternatural appear-
ances were discovered  in the brain,  but
the lungs were dark and turgid with blood,
and presented  an appearance similar to
that which is observed  after the division
of the pneumogastric nerves. " I do not,"
says  Sir Benjamin,  " positively  conclude
from this experiment, that the animal died
from  an injury inflicted on the nerves of
the eighth pair, but I think that such a
conclusion is highly probable, and it be-
comes an object of inquiry, whether a pa-
tient having recovered from hanging, may
not, in some instances, die  afterwards from
the injury of the par vagum."
  With regard  to the treatment of as-
phyxia from suspension—or strangulation
—it does not differ much from that which
is applicable to asphyxia in general.  The
chief modification demanded is  the state
of engorgement of the venous system of
the outward head, produced by  the con-
striction of the cord.  The ligature must
be removed immediately  from the neck,
and the head and shoulders be elevated:
the body  should be  stripped,  and  ex-
posed freely to the  air, even when  the
temperature is  somewhat low.  The ap-
plication of heat is the more unnecessary
in this  case, as the body has  not been
immersed  in a  cold medium, as in cases
of drowning.  Artificial respiration must
be adopted as soon as possible,  with the
other agencies  and cautions that have
been  already advised.   Bleeding may be
useful, to  relieve the turgescence of the
external vessels,—but  only for  this pur-
pose.  Especial care must be taken not to
extinguish the flickering spark of vitality,
and it  need scarcely be  observed, that
during recovery, the abstraction of blood
may be practised  with great advantage,
should symptoms of irregular vascular ac-
tion about the  head seem to indicate its
employment 
498
ASPHYXIA. (Of New-born Infants.)
  c. Asphyxia  from smothering does not
differ, in its essential phenomena, from the
other varieties.  Except  in  the  case  of
children, and even in them, it may be  re-
garded  as  a  rare occurrence.  Occasion-
ally it occurs to them as an accident, or
perpetrated as a crime. It is possible, too,
for an adult  in a state of intoxication or
great debility, to get into such a position
as to prevent the entrance of air into the
air  passages.  Death, too, is  not  unfre-
quently produced by what is called ' over-
laying  children,' which does only mean
that they  are  smothered  by the  mother
lying upon them.  Fatal  accidents have
happened  from the  young  infant being
pressed too closely against the side of  the
mother during her sleep, so that respira-
tion has  been arrested; and it has hap-
 pened, that fatal asphyxia has been caused
 by the  anxious care of the mother to wrap
 her infant so as to shield it against the in-
 clemency of the weather.  (Annual Regis-
 ter,  for  1816.  Chronicle,  p. 147;   and
 Smith's  Forensic Medicine, 2d edit pp.
 246 and 249.)  Children, again, have been
 smothered by  being folded up in a sort of
 turn-up bedstead, once much employed by
 the poorer classes especially,—in a double
 capacity,—
    " A bed by night; a chest of drawers by day."
    The same differences may occur in this
 variety of asphyxia  as in those that have
 been considered,—according as the condi-
 tion has been  induced at once,  or as re-
 spiration  may have  gone on,  though im-
 perfectly, for a time.
    As to the treatment, it is precisely that
 which has been laid down under the for-
 mer heads, with  the exception  of the
 means demanded for their peculiarities.
 Asphyxia from smothering may,  indeed,
 be looked upon  as the most simple form:
 to it therefore, the  directions for the ma-
 nagement  of asphyxia  in general  are
 strikingly appropriate.
    d. Among  the  causes that give rise to
 asphyxia, by  preventing  the entrance  of
 air into the lungs, are enumerated;—ob-
 struction of the air passages by  the  en-
 trance of extraneous  bodies,  by the pre-
 sence of tumours,  or  by any morbid
 thickening of the  lining  membrane  of
 the tubes.  For an account of  the  pa-
 thological phenomena, which  are conse-
  quences of morbid actions going on in the
  parts, we must refer to those  articles  of
  the 'Cyclopedia'  which are devoted  to
  the consideration of such lesions.  It need
  scarcely be said, that if such extraneous
  bodies or morbid conditions shut off the air
  at once, simple asphyxia is produced; if
more slowly, the phenomena—as in other
varieties of asphyxia—must be modified
by the circumstance, and that the cases
will have to be treated—medically or sur-
gically—according to rules laid down  un-
der the appropriate heads. The same may
be said of asphyxia produced by wounds
in the parietes of  the chest, which admit
the air freely into  the cavities of the pleu-
ra, and occasion contraction of the lungs.

   By  those  who  have   employed  the
term 'Asphyxia' in its wide acceptation,
many other varieties have been admitted.
Thus, Most (Art. Asphyxia, in Encyklo-
padie u. s. w.) enumerates Asphyxia from
drinking;  A. from poisons; A. from cold;
A. from  lightning;  A. from hemorrhage;
A. from  violent passions or emotions;  A.
from concussion  or contusion;  A. from
luxation of  the cervical vertebra; &c.;
but, according to the definition of asphyxia,
given in this  article, their consideration
would manifestly  be out of place here;—
the first link in the  chain  of morbid phe-
nomena being seated in the functions of
 innervation  or circulation,  rather than in
 that of respiration; yet Dr. Kay, who, as
 we have seen, has so well explained the
 theory of asphyxia, has indulged in an
 episode  on  Death  from cold  (see Cold),
 which is as much  out of place as would
 have been Death  from apoplexy, or many
 of those other varieties that have been ad-
 mitted by Most, Wagner,  and such as al-
 low a more extended  acceptation to  the
 term.   There is a form of  asphyxia, how-
 ever, which may, with much propriety, be
 considered  in this place,—according to
 the views which we embrace of its theory
 and phenomena.   We allude to the  As-
 phyxia of the new-born infant.
    e. It is well known, that during intra-
 uterine life, no more blood passes through
 the lungs than is necssary for their nutri-
 tion, and that the blood  of tbe foetus is
 sent to the  placenta, whence it passes
 back by the umbilical vein; doubtless after
 having experienced some  changes in the
 placenta, which better adapt it for the nu-
 trition  of the new being.
    The  precise mode, in which the nutri-
 tion of the foetus  is  accomplished, has been
 a topic of discussion amongst physiologists
 for ages.   The facts and arguments ap-
 pear to us decidedly in favour of the view
 which considers, that the human placenta
 has no  direct agency in embyotrophy, and
 it seems to us, that all that is necessary—
 in order that a foetus shall be developed in
 utero—is, that there shall  be an absorbing
 surface surrounded by a  nutritive  sub- 
ASPHYXIA.  (Of New-born Infants.)
490
stance, which will admit of being absorb-
ed.   Now, the cutaneous envelope of the
foetus—monstrous  or  natural—is such  a
surface, and the liquor amnii such a fluid;
whilst the matter of the umbilical vesicle,
and the jelly of the cord, when these parts
exist, and j)Ossibly some material derived
through the  placenta—after  it exists—
may lend their aid, but the participation
of the last organ is certainly questionable.
Its  function is probably to admit of the
foetal blood being shown to that circulating
in the maternal vessels, in order that some
change may  be  effected in the former,
which may better adapt it for serving as
the pabulum, whence  the secretions from
which the foetal organs have to be  elabo-
rated, must be formed. (Human Physio-
logy, II. 405.  2d. edit.; and  American
Journ. Med. Sc. No. 28, for August, 1834.
p. 411.)  The placenta, in other words,
may be esteemed  a respiratory organ for
the foetus;  and yet its  presence does not
appear to be indispensable, as there are
many well authenticated cases of children
having undergone intra-uterine develop-
 ment  in the  absence of umbilical cord,
 umbilicus, and placenta.  Still, when these
 parts have once  existed, they are  neces-
 sary for complete foetal development, and
 anything that  interferes  with the  due
 passage of the blood  along the cord, will
 produce asphyxia,—not only  by prevent-
 ing the requisite changes of the blood  in
 the placenta, but by the interference with
 the  circulation, which has to be effected
 by tlie umbilical  cord and placenta, until
 the independent circulation is established
 by pulmonary respiration. (Velpeau, Trai-
 te elementaire de Vart des accouchemens,
 &c. p. 925.)   We can  thus  understand,
 that if the cord  comes  down in  such a
 manner as to be strongly compressed for
 some time  before delivery, asphyxia  may
 be  produced;—should the cord, for exam-
 ple, descend before, or with, the head.  In
 like manner,  when  the  breech, feet,  or
 knees, present, there  is  danger  to the
 child, unless  the delivery be  rapid.  Oc-
 casionally, too, the child  is still-born, ap-
 parently in consequence of some morbid
 condition of the  organs  of  innervation.
 Thus, owing to pressure of the  child's
 head, in its passage through the pelvis, or
 to  some modification in  the  encephalo-
 spinal centres, or in the nerves distributed
 to  the respiratory organs, the function of
 respiration  is not established,  notwith-
 standing that the circulation appears to go
 on well  along the cord: the child seems
 to be in an apoplectic condition.
  Asphyxia may persist longer in the new-
born child than in the  adult, in conse-
quence of the powers of calorification be-
ing but imperfectly developed, and there
being,  in consequence,  less  need for  a
highly oxygenized blood  for its support.
  It has been a question, whether the um-
bilical  cord should be  divided  in these
cases as soon as the child is extruded.  In
reply to this it may be  remarked, that if
all  circulation has ceased in the cord,
there can be  no advantage whatever, in
keeping the connexion between the child
and the placenta entire,  especially as the
union cannot fail to interfere with the due
application of such means  as  may be re-
garded necessary.  Indeed, where the cir-
culation continues, but is becoming weak-
er,  whilst the breathing  has not  com-
menced,   it has been properly  doubted,
whether if the connexion with the mother
interfere with the  application  of  other ef-
ficacious means, it should be permitted to
continue, when, owing to the placental cir-
culation having become weaker,  it seems
evident that the application of such means
cannot be longer delayed with impunity.
(Kay, Op. Cit. p. 89.)
  Sometimes, when the  child is extruded
and the  placental circulation continuing,
the  stimulus of a smart  stroke on the
breech will arouse the  dormant energies,
and the  child will immediately begin  to
cry; but  if this is insufficient, the infant
had better  be exposed  to a moderately
warm  temperature, that is, to the mode-
rate warmth of the fire, but so that the
air can come  in contact with a large sur-
face of the body.  Edwards found  that
the young of some species of warm-blood-
ed  animals,  when  deprived  of  air,  live
longest  in  a temperature of about 6^°
Fahrenheit and this may be taken as  a
guide  to  the proper  temperature for  the
still-born infant.  Generally, immersion in
a warm bath  is had recourse to, but  the
rationale of its action is by no means un-
equivocal, whilst  as Dr. Kay has observ-
ed,  it is  not  necessary to the application
of a proper degree of warmth to the body
of the child;  it prevents the beneficial ef-
fects of the atmosphere  on the skin;  and,
moreover, it is found, as we have seen, to
exert  a depressing influence  on the nerv-
ous and muscular systems.
   In addition to these means,  friction with
 the dry  hand,  or  with stimulating  lini-
 ments, especially over the regions of the
 chest and stomach, as well as the applica-
 tion of spirits to the nostrils, to rouse the
 respiratory nerves to action, have been re-
 commended.   Should any mucus obstruct
 the mouth and pharynx, it ought to be re- 
500                   ASPHYXIA.  (Of New-born Infants.)
 moved by means of the finger  enveloped
 in  a piece  of fine linen, dry or dipped in
 a solution of common salt
   But, after all, these means will often be
 found unsuccessful, and it becomes neces-
 sary to have recourse to artificial respira-
 tion.  This  is, indeed, the great reliance
 of the practitioner in severe cases, and its
 salutary influence is frequently very mark-
 ed.   Whilst artificial respiration is persist-
 ed in, the cord will often be observed to pul-
 sate, and to  cease when the  operation is
 suspended.   In  the still-born fetus,  it is
 not found practicable to execute artificial
 respiration by mere pressure on the chest,
 in the mode recommended for the adult.  In
 one case, Dr. Blundell (The Principles
 and Practice  of Obstetricy, Amer. edit. p.
 162.) diligently operated in that manner
 for  fifteen or twenty  minutes together,
 without  producing resuscitation, and,  on
 examining the child on the following day,
 he  found that scarcely a particle of air
 had entered the lungs.   Nor can insuffla-
 tion be  readily effected by blowing  in at
 the  mouth.   The only mode of doing it
 effectually is by means of the curved ca-
 nula or some  analogous instrument.   We
 are  in the habit of car-
 rying a  tracheal pipe, ^^\
 of  which the annexed    >\
 figure is a representa-        >^\
 tion.   It is a little tube         \\
 of silver, with  its ex-          \\
 tremity  closed, and an           \ '
 aperture near the ex-            I
 tremity to give passage            I
 to the air and  mucus.            I
 The introduction of this           I I
 instrument into  the la-           / I
 rynx is by no means dif-           / /
 ficult, with a little care.           / /
 All that  is necessary is,           / I
 to pass the forefinger of           11
 the left  hand upon the         / /
 root of the tongue as far         / /
as the opening  of the          / /
larynx, and  then to in-          / /
sert the  tube, held in         / /
the  right hand,  along         I /
the finger as a director.         / /
It will readily  enter, and         J_\
by pressing on the neck,        <§}
it can easily  be disco-
vered, whether the instrument  is in the
trachea  or  the  oesophagus.  The  lungs
may then be  inflated by blowing air from
the lungs of the  practitioner  through the
 tube, and then  forcing it out  again by
pressing  on the thorax and abdomen, and
 repeating this five and  twenty or thirty
 times in a minute,—the  respirations of the
 new-born  infant being  as numerous as
 that.  It has been objected,  that the air,
 sent into the lungs of the foetus from those
 of the adult cannot be  as efficacious as
 pure atmospheric air; but it is to be borne
 in mind, that the young being does not re-
 quire such highly oxygenized  air as the
 adult; and moreover, Heroldt found, that
 air inspired, and expired immediately af-
 terwards, had only one hundredth part less
 of oxygen than common atmospheric air.
 This objection, therefore, is more plausi-
 ble than real.  In inflating, care must be
 taken, as we have  previously inculcated,
 that it is  not  driven in too powerfully.
 The experiments of  Leroy d'Etioles show,
 that insufflation  may be performed  with
 much less risk in the infant than in the
 adult, because the structure of the lungs
 is firmer in the former, and consequently
 there is less danger of rupture  or dilata-
 tion of the  air cells.
  If the bellows of Leroy are at hand,
 which they scarcely ever are, on such oc-
 casions, they may be employed.  It has
 also been  proposed, that  a small galvanic
 apparatus,  like that recommended by Le-
 roy, and before described, might be used
 witli advantage to rouse the diaphragm to
 contraction.  "The  acupuncture needles
 might be introduced into the diaphragm,
 one or two lines on each side of the chest,
 and two wires, each leading to  an oppo-
 site pole of the  galvanic  circle, might be
 connected with these needles.   On com-
 pleting the galvanic circle, a contraction
 of  the  diaphragm  would  be. produced,
 which might be suspended by removing
 one wire,  for a moment, from its connex-
 ion with the battery.  The relaxation of
 the muscle might then be effected by gen-
 tle pressure on the abdomen, and this pro-
 cess might be  alternately repeated until
 respiration  was  established." (Kay,  Op.
 Cit. p. 93.)
  Such appears to be the  most  approved
 mode of resuscitation in cases of the As-
 phyxia neonatorum.   Desormeaux, how-
 ever (Art. Nouveau-ncs, in Diet, de Med.;
 and Velpeau, Op. Cit.),  complains of his
 want of success from inflating the lungs,
 even when assiduously used, and he places
 his  main- reliance on external means for
 exciting the respiratory muscles to con-
 tract.  For this purpose, he  recommends
 a species of douche or ablution with some
 alcoholic  liquor.   This  the practitioner
 takes into  his mouth, and having held it
 there a few seconds,  he ejects it forcibly
against  the anterior paries of the in-
fant's chest.  It is   rarely necessary, he
says, to repeat this  more  than  twice or 
                      ASPHYXIA. (Of

thrice.  Velpeau says he has adopted the
plan, and with success.
  It has been also advised, that a cupping-
glass  should be  applied to the nipples of
the child, or  that they should be sucked
by the mouth (Van Swieten,  Saccombe,
and also Wagner,  in  Encyclopddisches
 Worterbuch, &c. Band III.  s. 557.); but
as Desormeaux has remarked, the  only
use in this can be to excite  the action of
the muscles. It is utterly impossible, that
any dilatation of the chest  could be pro-
duced by it, as has been believed by many,
who were more credulous than judicious.
(Velpeau, Op. Cit.  p. 927.)
  It is  unnecessary  to  dwell upon the
many other  expedients that have been oc-
 casionally adopted.   If the means pointed
out should fail, we ought not to expect ad-
 vantage from such agents as the smoke of
 linen or burnt paper, or onions or garlic
 introduced into the  rectum*  or the appli-
 cation of stimulants to  the  nose.   Their
 cautious use may be advisable when the
 spark begins to be ignited, but not before.
  When the means are beginning to suc-
 ceed,  tlie  pulsations of the  heart  and of
 the cord—if the child be still attached—
 gradually return; the muscles resume, by
degrees, their natural firmness; the  skin
 becomes less pale, and calorification is re-
 established.  Some slight convulsive gasps
are made,  which become  stronger  and
stronger, and  ultimately the child attains
sufficient vigour  to cry, after which  it may
be looked upon as safe.  This, at least, is
a general  rule; but every  practitioner
must  have had the  mortification to find,
that even when  he has succeeded so far,
unfavourable  symptoms  have presented
themselves,  and the child has sunk.  Vel-
peau refers to two cases in which  he had
succeeded in restoring the movements of
the heart  and the  lungs for more than
three hours, by means of insufflation  and
galvanism;  yet  both infants were  subse-
quently lost.
  The same question has been agitated
here, as in other cases of asphyxia:—How
long ought we to persevere  in our efforts
at resuscitation?  It has been advised,
that they should not be relinquished un-
der two or three hours,—but all this must
be decided upon  by the good sense of the
practitioner.  Let him bear in mind, that
many  a  child  has been thrown aside as
dead,  which might  probably have been
saved.  A woman, run  over by a  stage,
was carried  into St. Thomas's Hospital,
London, and died in a few minutes after
admission.   Dr. Blundell was requested
by Mr. Green to assist in the Csesarean
New-born Infants.)                  501

 section.  In thirteen minutes  from  the
 last respiration of the mother, the child
 was taken out.  In fifteen minutes from
 the last  respiration  of the mother,  Dr.
 Blundell began the artificial respiration,
 and,  during fifteen  minutes longer, he
 continued it.  Ultimately,  the child was
 completely resuscitated, and, according to
 Blundell, if due care had been taken of
 it, it  would  probably have been living
 still.   He affirms, also (Op. Cit. p. 164.),
 that a  Mr. Tomkins of Yeovil, a gentle-
 man  very accurate  in  his observations,
 used  resuscitants  for an hour  and five
 minutes by the watch, before obvious signs
 of life  appeared.   The  child  recovered,
 and lived for some time afterwards.
   Still, much  must be left to  the  judg-
 ment of the  practitioner.  Where, from
 the appearance of the foetus or other evi-
 dences, he has reason to believe, that it
 has been for some time dead in utero, all
 his endeavours must necessarily be abor-
 tive.   It is  only in  cases  in  which  the
 child has perished in the birth, that means
 can be available,—and in  such case all
 the energetic  measures,  which we have
 recommended, should be put in force, and
 not abandoned until all hope is lost.  Mr.
 Burns  says, that when a child does not
 breathe soon after it  is born, it  is not al-
 ways easy to say whether  it is alive, as
 we have, at this  time,  no criterion of
 death except putrefaction; and  therefore,
 that it behooves  us  always,  unless this
 mark is present, to use means for preserv-
 ing the child.   His remark might be  ex-
 tended  to every case of apparent death
 happening at any age, but  there is gene-
 rally  a catenation  of phenomena,  which
 enables us to pronounce with tolerable cer-
 tainty before this criterion of death is ob-
 servable. (Principles of Midwifery, Book
 iv. chap. 1. sect. 1.)   There  can be  no
 doubt however, that so long  as there is
 any hesitation  in the  mind of the practi-
 tioner as to whether the child is dead or
 not, his efforts should be  perseveringly
 continued.
   Where  there is  any reason  to believe
 that the state  of suspended animation is
 dependent on, or connected  with, an apo-
 plectic  condition,—as where the respira-
 tion is  very slow and laborious, and there
 is evidence of venous engorgement of the
 head and neck, with pulsation in the cord
 —advantage is often derived  from per-
 mitting a  tea-spoonful or two of blood to
 flow.
   Where  the  attempts  at resuscitation
 have  been successful, in  the case  of as-
 phyxia  of the new-born, the same  atten- 
502                          ASPlD.—ASSAFET.
tion  is necessary  during recovery—that
is, for a day or two afterwards—as in the
varieties  of asphyxia  previously  consi-
dered.
  Bibliography.—The different writers on Ob-
                  Robley Dunglison.
   ASPIDIUM.  (Botany.)
   A genus of ferns, separated from Po-
lypodium,  from having the fructification
covered with an involucrum.  It contains
several species that  have been employed
as therapeutic agents, and have attained
much celebrity as anthelmintics, &c, more
especially the A. filix mas.
   A. filix mas.   Male fern.   Fougere
male, Fr.;  Johanniswurzel, Germ.   Sp.
Ch.  Fronds bipinnate; pinnules  oblong
obtuse,  serrated;  serratures mutic; sori
near the  central nerve; stipe and rachis
chaffy. Hooker.   The male fern is found
in most parts of the world, and is abund-
ant in certain districts in the United States,
principally  in shady pine  forests.  The
American plant  is said by Pursh to have
the leaflets  more obtuse, and oftener dou-
bly serrate than the European:  this, how-
ever, is not invariably the case,  as speci-
mens are often found agreeing in every
particular with those from England, &c.
   The root which is the officinal part, is
perennial, but the fronds are annual.  This
root, which is in fact  a true rhizome, is
horizontal,  and  consists of tuberculated
portions, connected by a common axis, and
separated from each other by membrana-
ceous, silky scales  of a brown colour. The
radicles or true roots Issue  from the ex-
tremities  of these tubercles. The fronds
or leaves are numerous, and are from one
to three  feet in length.   The footstalk is
of a brown colour and covered with brown
membranaceous scales.  The frond  is bi-
pinnate,  of a bright green  colour.  The
leaflets are deeply divided into lobes of an
ovate form, cuneate  and gradually dimin-
ished in  size as they approach the extre-
mity of  the leaf.   The fructification  is
borne on the back of each lobe, and con-
sists of rows of  small brown dots situated
near the middle nervure. (See Felix mas.)
   The A. baromelz,  or Sythian lamb, re-
specting  which so  many absurd fables
have been propagated, has roots which are
covered with fine brown  scales  resem-
bling hair. These  rhizomes  are ofa large
size, and are highly esteemed in China as
an astringent in external hemorrhages, as
well as in diarrhoea and other discharges.
  The Cahahuala  of Peru, in such gene-
ral use among the natives,  in rheumatic
and  syphilitic affections,  and spoken of
in  exalted terms  by  Ruiz  and  otlier
Spanish authors, as a remedy in pleurisy,
and, in fact in  almost every disease, ap-
pears to be either a species of Aspidium
or of Polypodium, though  the  accounts
given of it are too vague and confused to
determine  the point with certainty.
                      R. E. Griffith.
  ASPLENIUM. (Botany and Mat. Med.)
  Gen.  Ch.  Sori linear, transverse, scat-
tered.   Involucri arising from the lateral
veins,  and  opening towards the central
nerve or rib.  Hooker.
  This  genus of ferns is not very numer-
ous, though its different species are found
in most parts  of the world,  on rocks and
old walls.   In  its  medical properties it
closely  resembles Adiantum  (q. v.),  but
does not possess the aroma of the officinal
species  of that genus.  At  one  time  the
A. ruta muraria was highly esteemed and
considered as a panacea in all inflamma-
tory disorders.   As, however, the only
qualities it possesses are those of a mild
astringent  and demulcent, it is at present
only employed as a substitute for the true
Maiden-hair in  making capillaire. None
of the species are  recognized in the U.
States Pharmacopoeia, but several are con-
sidered  as  officinal  by  the French and
German.   Descourtilz  states  that  the
A. serratum, a native of the West Indies,
has been found useful in obstinate diar-
rhoeas, in doses  of one to three drachms.
(Flore Med. des Antilles, II. 337.)
                      R. E. Griffith.
   ASSAFETIDA.  — Assafcetida, Ph.
U. S.—Assufuilida, Fr.; Stinkasant, Teu-
felsdreck,  Germ.
  Origin,  and Commercial History.  As-
safetida is the concrete  juice of the Fe-
rula Assafcetida, an umbelliferous plant
growing in Persia and the countries which
border upon that kingdom upon  the east.
(See Ferula.)   In the Amenitates Exo-
tica of Kaempfer, published in the begin-
ning of the last century, after the return
of that  traveller from Asia,  the following
account  is given of the mode in which
the juice is collected in the mountains of
Chorassan  and  Laar.  In the choice of
plants,  the oldest are  selected, as  the
young yield little juice; and  it is never
thought worth while to  cut those which
are less than four years old.   At the sea-
son when the  leaves begin  to decay,  the
earth is cleared away  from around  the
upper part of the root, which, when  full
grown,  is as large as the arm or leg of a
man. The stem and leaves are then twist-
ed off, and, together with other  vegeta-
bles, are placed  over the root so as  to 
ASSAFETIDA.                              503
screen it from the sun, being retained  in
their situation  by a large stone laid upon
them.  These  are  allowed  to remain for
forty days, after which they are removed,
and the  top  of the root is cut off trans-
versely.  The surface thus exposed is pro-
tected from  the  sun by  a covering  of
leaves for forty-eight hours, during which
a portion of juice exudes. This is scraped
off* and  another transverse slice of the
root is removed,  in order to afford a fresh
surface for exudation,  from  which the
juice is  collected as before.   This opera-
tion is repeated several times,  an interval
of eight  or ten days being allowed after
the third section, in order that the root
may have  an opportunity to recruit   A
period of nearly  six weeks elapses before
the root  is quite exhausted.   The juice,
when collected, is exposed to  the sun  in
order that  it may harden; and as the pro-
duct of different  roots is put together  by
the peasants, the mass assumes that hete-
rogeneous  appearance which assafetida
presents  as it  is  ordinarily found in com-
merce.   When sufficiently concrete, it is
enclosed  in mats,  and sent to Bushire upon
the Persian Gulf, whence it  is shipped to
Calcutta, and from that port is distributed
over the  world.   It is imported  into this
country either in  the  original mats, or  in
cases in which it is packed at Calcutta.
   Sensible properties, composition, Sic.
Assafetida is in masses of different sizes,
and of variable consistence, according to
its  age and  the  degree  of exposure  to
which it  has been subjected.   Sometimes
it is rather soft  and  adhesive, sometimes
hard and firm, requiring considerable force
to break  it. When quite dry, it is brittle,
but not readily pulverizable, unless at a
low temperature.   It may be powdered in
winter, and by sifting may be  freed from
the coarse impurities with which it  is
sometimes associated.  Its fracture has a
lustre like  that of wax.  The freshly bro-
ken surface is  usually more or less diver-
sified,  exhibiting white, shining, smooth,
homogeneous  parts,  intermingled  with
others of a darker colour and less uniform
aspect; as if the mass consisted of sepa-
rate portions agglutinated together.
  The colour of assafetida, when recently
broken, is whitish,  but soon  becomes red-
dish upon exposure, and gradually deepens
into a  violet  red, which  is  ultimately
changed to brown.  The outer surface  of
the masses is usually yellowish or reddish-
brown.   The  odour  is peculiar, strong,
fetid, and to most persons excessively dis-
agreeable.  It  was this property which
gained for the drug among the Germans
the expressive name of Teufelsdreck or
Stercus Diaboli.  It is not difficult  how-
ever, to become reconciled  to the odour,
and there are  not wanting individuals for
whom  it has  strong attractions.   It  is
much more powerful  in the recent drug
than in that which has been  long exposed;
and Kaempfer states  that one drachm of
the fresh juice emits a stronger  smell
than one hundred pounds of the concrete
masses found  in the shops.  The taste is
bitter, acrid, and durable.
  Exposed to a moderate heat assafetida
softens and becomes adhesive, but never
completely melts.  It is inflammable, burn-
ing with a clear lively flame.  It imparts
its sensible properties and medical virtues
to alcohol, forming a transparent tincture,
which is rendered milky by the addition
of water.  Macerated with water  it af-
fords a  reddish turbid solution, and  tritu-
rated with that fluid, an  opaque emulsion,
which  is at first white, but becomes of a
pink colour upon exposure.   After stand-
ing for some time,  it deposits the resinous
portion.
  Assafetida is usually ranked among the
gum-resins, and consists, according to the
analysis of Brandes, of 4.6 parts of vola-
tile oil,  47.25 of  an odorous bitter resin
soluble  in ether, 1.6 of a tasteless resin
insoluble in ether,  1.0 of extractive, 19.4
of gum containing traces of potassa and
lime united with  sulphuric, phosphoric,
acetic, and malic  acids', 6.4 of bassorin,
6.2 of sulphate of lime, 3.5 of carbonate
of lime, 0.4 of oxide of iron and alumina,
0.4 of malate of lime with resin,  6.0 of
water, and 4.6 of impurities consisting
chiefly of sand and  woody fibre.  The pro-
portion of the ingredients no doubt varies
considerably in different  specimens.   The
volatile oil is  most abundant in the recent
drug.  It is upon  this principle that the
odour of  assafetida depends.  It may be
obtained separate  by distillation with wa-
ter.  It  is  limpid  and  colourless  when
fresh, but becomes yellow  by  age.  Its
specific gravity is  less than  that of water.
Its  odour is exceedingly powerful and of-
fensive ;  its taste at first flat, but ultimate-
ly bitter and acrid.  Water dissolves  it but
very slightly,  alcohol and ether in all pro-
portions.  It  is said to  contain sulphur.
The medical virtues of the drug reside in
the volatile oil, and in  the  bitter resin;
and it is a question whether the latter in-
gredient does not  owe  its  efficacy to a
small portion  of the oil  tenaciously com-
bined with it.
  In the selection  of assafetida,  those
pieces should  be preferred which are free 
504                              ASSAFimDA.
from  obvious  impurities,  present when
broken a white shining surface, and have
in a high degree the peculiar odour of the
gum-resin.
   Effects upon the system.   Assafetida is
stimulant antispasmodic, expectorant lax-
ative, and perhaps emmenagogue. Taken
internally, it produces a feeling of warmth
in the stomach, which is soon followed by
a  moderate excitement of the heart and
arteries, increased heat of skin, and some-
times gentle  diaphoresis.   At the  same
time  it exerts a  powerful influence over
the nervous system, which is evinced ra-
ther by  its efficacy in relieving certain
morbid conditions, than by any very obvi-
ous phenomena during health. It appears,
however,  sometimes to occasion mental
excitement and exhilaration of spirits; and
in large doses gives rise to swimming in
the head, dizziness, and other indications
of disturbance in  the nervous functions.
It is generally admitted to have  an espe-
cial tendency to the  pulmonary organs,
and to  stimulate the  bronchial  mucous
membrane to  increased secretion.  Some
believe that it exerts a peculiar influence
over the uterine system, calming the irri-
tations to which it is exposed, and pro-
moting  and sustaining the  menstrual ef-
fort Its stimulant action is also decidedly
felt by  the stomach  and bowels,  as  is
evinced by the local sense of warmth and
the laxative effect which result  from its
use in the healthy state, and still more by
its happy influence in certain debilitated
conditions of  these parts.  In large  doses
it sometimes acts as a purgative.  There
is no reason to doubt  that  it is absorbed
from  the  alimentary canal, and  operates
upon the general system through the me-
dium  of the circulation;  for after it has
been used for a short time, its odour is per-
ceived in the breath, and in all the secre-
tions, even those of a morbid character;
and it is even  asserted that sensitive indi-
viduals can perceive its taste in the mouth
when it has  been  administered  by the
rectum.                                g
   Therapeutic applications.   Assafetida
was probably used by the ancients both as
a medicine and a condiment. It is thought
to have been the  gOj^iov or  ortoj ccktyus of
the Greek writers, and the laserpitium or
laser of the Latin.  By the earlier modern
medical writers it is commended as a re-
medy in  nervous  affections;  and  most
practitioners at present agree with Boer-
haave and  Cullen in considering it  as
one of the most powerful antispasmodics.
In Persia and India it is said to be less
employed as a medicine than  as  a condi-
ment.  The Brahmins use it habitually to
obviate the flatulence occasioned by their
vegetable diet; and we are told by Ains-
lie that they  consider it digestive and
aphrodisiac.
  This remedy is indicated in all spasmo-
dic complaints and other cases of nervous
derangement, unconnected  with  excite-
ment of the circulatory system, or with
local  inflammation;  and especially when
these affections are associated with or de-
pendent on general debility.   Even in in-
flammatory complaints,  when the nervous
system is thrown into great agitation, the
use of assafetida is  frequently admissible
after  due depletion,  or after the partial
subsidence of excitement in  the natural
progress of tlie disorder.  This remark is
especially true  of the pulmonary  affec-
tions, in which the  union of expectorant
with antispasmodic properties  renders the
medicine peculiarly useful.   Simply as a
stimulant expectorant it will be found oc-
casionally advantageous in chronic bron-
chial  disease.  Its  excitant and laxative
properties adapt it also admirably to cer-
tain morbid conditions  of the alimentary
canal, in which costiveness and flatulence
are associated, as is frequently the case in
old people,  with deficient irritability of
these parts.  It is  obviously  contra-indi-
cated in cases of general plethora, or in-
flammatory excitement, and especially by
acute inflammation of the alimentary mu-
cous membrane.
  From these remarks it may be  inferred
that assafetida is very  extensively appli-
cable as  a therapeutical agent.  With-
out attempting to particularize every va-
riety of morbid affection in which  it has
been employed or recommended, we shall
indicate those complaints in which either
decided  indications  for its  use  are pre-
sented, or respectable testimony to its fa-
vourable influence can be adduced.
  In  hysterical  disorders  assafetida  is
often  highly advantageous.   It probably
acts here not only by its general influence
upon  the nervous system,  but also by its
fetid odour, which gives a new direction
to the nervous irritation, and thus for a
time relieves  the existing symptoms.  It
is, however, only in  the lighter forms  of
the complaint that it does good in the lat-
ter mode.  In  hysterical colic it will  be
found peculiarly useful. In  certain con-
ditions of hysteria, in which it is impossi-
ble to administer the remedy by the mouth,
it may  be advantageously given  in the
form of enema.   Such are the convulsive
paroxysms, and the conditions of insensi-
bility more  or less complete, which fre- 
ASSAFETIDA.                             505
quently occur in this disease.  Assafetida,
however, must be regarded rather  as a
palliative than  as a remedy in hysteria,
and should  be  used  only  as  an adju-
vant to  means directed to the root of the
disorder.  It may sometimes even do harm
if employed without attention to the con-
dition of the circulation, or to existing in-
flammatory affections.
  The foregoing remarks are equally ap-
plicable to hypochondriacal affections, in
the treatment of which assafetida has long
enjoyed a high reputation.  Persons of ex-
citable nervous systems  are occasionally
subject to vertigo, dizziness, fainting spells,
and various anomalous disorders of a nerv-
ous character, in all of which this medi-
 cine will prove useful if applied with pro-
 per discrimination.
   In obstinate singultus it is perhaps next
 to musk the most effectual remedy.
   In  infantile convulsions dependent on
 intestinal spasm it is doubly useful, by re-
 lieving the local affection, and by control-
 ling that excitable condition  of the nerv-
 ous system which renders it so liable, in
 children, to be  thrown into irregular  ac-
 tion by any local irritation.   In the con-
 vulsions  caused  by dentition, worms,  and
 other local  affections  unconnected  with
 the brain, it sometimes acts favourably, if
 given in the intervals of the paroxysms,
 in  preventing their  return.   Great care,
 however, is necessary in properly discri-
 minating such cases  from  those purely
 cerebral, and in avoiding the risk of too
 much arterial excitement.
   Cases of cures of  epilepsy by means of
 assafetida are on record; and there is no
 doubt that in the purely nervous forms of
 this complaint  it may occasionally prove
 useful.
   In  chorea it may sometimes be given
 advantageously, though in the majority of
 instances this disease is greatly beyond its
 reach.  An obstinate case, which  had re-
 sisted the  most powerful remedies,  was
 cured by the following combination:—
   R. Assafoetid., Extr. Valer. aa 3ii, Extr.
 Belladon. gr. v, Oxid. Zinci Bi, Castor, gr.
 xxxv:—to be made into pills of two grains
 each, five of which are to be taken three
times a day. (Gunther, quoted by Rich-
ter, Arzneimit. II. 20.)            .
   Assafetida has been  used  in typhoid Je-
vers,  and may be found advantageous id
cases attended with  nervous derangement
without decided symptoms of cerebral dis-
ease  or  intestinal inflammation;—but in
general its good effects may be more rea-
dily obtained from other less objectionable
remedies, and it is now seldom employed.
  VOL. II.          43
When given in these complaints, it is best
administered  in the form of enema; as its
constitutional impression may thus be ob-
tained with less danger of irritation to the
mucous membrane of the  stomach and
small intestines.
  But the complaints in which  the pow-
ers of assafetida are most  favourably ex-
ercised  are the spasmodic  pectoral affec-
tions.  In hooping-cough it is one of the
most  effectual remedies to  which we can
have recourse.  In this disease it was ex-
tolled by  Millar, and  has subsequently
been  much employed.  In the  different
forms of asthma  it will occasionally do
good—in  the spasmodic, by affording re-
lief to the paroxysm, and  in the  variety
usually denominated humoral, by its com-
bined antispasmodic and expectorant pro-
perties.  Dr. Chapman  speaks  in strong
terms of its efficacy, when given in large
and frequently repeated doses, in the asth-
matic paroxysm. (Elem. of Mat.  Med. and
Therap. II. 297.) Cullen, however, states
in his Mat Med. that he has seldom found
it of much service in this complaint.  In
couglis dependent upon  nervous  irritation,
which are not very uncommon, we have
often found the most decided benefit from
assafetida; and catarrhal affections, which
are sometimes rendered, obstinate by such
a complication, will, after  due depletion,
yield to this, sooner than  to almost any
other remedy.  Dr. Joseph Parrish,  of
Philadelphia, has  found it of the highest
service in infantile catarrhs of  this char-
acter. (N. Amer. Med.  and Surg. Journ.
I. 24.)  In the inflammatory pectoral af-
fections of very young children  it not un-
frequently happens, either from the deple-
tion  employed,  or  from  the feeble re-
sources of the system,  that the strength
gives way before the disease has had time
to complete  its course, and  the patient
sinks under  a  complaint the natural ten-
dencies of which are towards  recovery.
The  ordinary stimulants cannot be safely
used, from the danger  of  rekindling the
declining inflammation.  Under these cir-
cumstances,  assafetida  exercises  a most
happy influence—imparting vigour to the
nervous system, which most stands in need
of support, and at the same time  operating
favourably upon the local  disease by pro-
moting expectoration.   The author is en-
tirely confident, that he has seen repeated
recoveries under this treatment in cases
which, without such support, or under  a
continued system of depletion, must have
proved fatal.  It may be stated, as a gene-
ral rule, that in all chronic bronchial af-
fections,  in  which the secretion from the 
506
ASSAFETIDA.
mucous membrane  is too abundant and
the lungs become loaded beyond the power
of convenient  expectoration,  assafetida
will do good, if given with a due regard
to the state  of the pulse and to the evi-
dences of local inflammation.   In the lat-
ter stages of phthisis it sometimes proves
useful  by facilitating  expectoration  and
relieving dyspnoea.
   In diseases of the abdominal viscera,
assafetida may often be  usefully employed
as a stimulant antispasmodic and laxative.
Cullen  observes  that  it is particularly
useful  in relieving  those spasmodic  com-
plaints which so frequently attend dyspep-
sia. In costiveness accompanied with flatu-
lence it may often be advantageously com-
bined with tonic and cathartic  medicines,
particularly in the  cases of elderly per-
sons, and those of a weak,  relaxed  habit
of body, with paleness of the surface, and
other  marks of a  leucophlegmatic  tem-
perament.  It  is  strongly recommended
by Richter, in combination with ox-gall
and rhubarb,  in dyspepsia attended with
acid in the stomach.  He employs the fol-
lowing formula:—R.  Assafcetida?,  Fell.
taur. inspiss. aa 3ii, Rhei pulv. 3ss:—to
be made into  pills of two grains  each,
twelve of which  are to be taken  three
times  a day.   (Richter, medic, chirurg.
Bemerk. 1.174.)  The German physicians
employ it in complaints dependent on  ob-
struction in the portal system.   In Hufe-
land's Journal (III. 595.), a case of jaun-
dice, approaching in character to the va-
riety commonly called  black jaundice, is
stated to have been cured,  after the fruit-
less employment of many other remedies,
by a mixture composed of tincture of as-
safetida, golden sulphur of antimony, and
oil of turpentine.  As an anthelmintic, as-
safetida has enjoyed considerable reputa-
 tion, but is now comparatively little em-
 ployed ; as, though not without some ver-
mifuge power, it is inferior in this respect
 to many medicines which  are less disa-
 greeable to the palate.  Still, it may oc-
 casionally be resorted  to with advantage
 in cases of worms, when these are attend-
 ed with symptoms of local  or  general
 nervous disorder.
   Assafetida is by  some writers extolled
 as a remedy in amenorrhoea, and other de-
 rangements of the uterine functions. Like
 most other stimulants it undoubtedly pro-
 motes the menstrual secretion, when made
 to co-operate with the  natural tendencies
 of the system; and it may be used advan-
 tageously in cases which present the dou-
 ble indication for emmenagogue and anti-
 spasmodic medicine; but in cases of sim-
ple suppression or retention of the menses
it  cannot be  relied on, and at best should
be employed only as an adjuvant to other
more efficient remedies.
   The German medical writers ascribe
considerable  resolvent powers  to assafe-
tida, and recommend its employment both
internally  and externally,  in  scrofulous
tumours and other chronic swellings and
indurations, and  in venereal and scrofu-
lous affections of the bones.  By some it
is even considered useful in caries.  The
probability is, that it does little other good
in these affections than to afford a gentle
support to the general vital powers, and
to obviate those nervous disorders to which
patients are incident in the course of most
chronic complaints.
   Dose, Preparations, &c.   The dose of
assafetida  is from five to twenty grains;
but in obstinate complaints attended with
considerable insensibility,  it may be in-
creased to a  drachm, two, three, or four
times  a day.   In consequence  of its un-
pleasant odour and taste, the form of pUl
is usually preferred when the dose  is not
large, and  a tardy operation only is re-
quired.  The pills may be made imme-
diately from the mass if it be first softened
by a moderate heat; but  as, when thu6
prepared, they are not readily dissolved by
the gastric liquors, a  better plan  is to in-
corporate the gum-resin with  some eub-
stance, which may separate its  particles
and render it more readily soluble.  The
Pilula Assafcetida, of the U. S. Pharma-
copoeia, consist of three parts of the gum-
resin and one part of soap.  Each pill con-
tains three grains of assafetida.   Instead
of soap, some soft extract such as that of
gentian, may be  employed.
   When the dose is large, or a speedy ef-
fect is demanded, the best form of admin-
 istration is usually that of emulsion. This
may be made by simply  triturating the
assafetida  with  water.   Gum  Arabic  is
 sometimes added in  order to  render the
 suspension of the resinous portion more
 permanent.  The Mistura Assafcetida of
 our national code contains two  drachms of
 the gum-resin in half a pint of water, and
 may be given in  the  dose  of one  or two
 table-spoonfuls.   From  its opaque milky
 appearance it is  often called  lac assafce-
 tida or milk of assafetida.  This is the
 form in which the medicine is  usually ad-
 ministered as an enema.  From  two to
 four fluidounces  may be given in this way.
   Another form in  which assafetida is
 often administered is that of tincture. The
 officinal Tinctura Assafcetida  is prepared
 with undiluted alcohol  or  rectified spirit 
ASSIMIL.—ASTHMA.
507
in the proportion of two ounces of the me-
dicine to a pint of the menstruum.   The
medium dose is a fluidrachm.  This form
may be preferred in cases of torpor of the
stomach or general debility; and is pecu-
liarly adapted to the cases of drunkards.
                      Geo. B. Wood.
  ASSIMILATION.  (From assimilare,
to render similar.)   The act  by which
living bodies convert into their own sub-
stance, foreign matters.  It is the ultimate
process of the series of actions which con-
 cur to effectuate the reparation of organ-
 ized bodies,  and constitutes  an important
 part of the function of nutrition.   (See
 Animalization, Digestion, and Nutrition.
                                I.H.
   ASTHENIA.  (From a priv. and odtvos,
 strength.)   Want of strength,  debility.
 This term,  if regard be paid to its  ety-
 mology, is  perfectly synonymous  with
 adynamia, but it has been frequently used
 in a more restricted sense to signify some
 form of this condition.   It  has not,  how-
 ever, been  uniformly employed to denote
 the same species of debility:  on the  con-
 trary, there is great discordance on this
 point among writers;  and therefore,  to
 avoid the ambiguousness that exists as to
 its signification, we shall employ it  only
 in its general acceptation,  that which  its
 etymology  indicates.  Our duty, never-
 theless, as  lexicographers,  calls upon  us
 to indicate  the principal meanings which
 have been assigned to it.  In the writings
 of Hippocrates it signifies a deficiency
 in the system to resist the action of mor-
 bific causes. The ancient nosologists, who
 constituted  a class of diseases named as-
 thenic, understood by  this appellation a
 debility of the whole organism or of some
 of its functions, without any reference to
 the powers of the  system to resist patho-
 logical agencies.  The celebrated Brown
 gave to this term a meaning founded en-
 tirely upon his particular doctrine.  Ac-
 cording to him, there exists in the organ-
 ism a  single  force, excitability,  which,
 maintained at a certain point, constituted
 health; when below this point asthenia.
 (See Brunonism.)
    Pinel (Diet, de Med. II.  401.) seems to
 have restricted  this term  almost exclu-
 sively to express the debility of old age.
 The author of the able article Asthenia; in
 the Dictionnaire abrege des Sc. Med. de-
 fines it to be " that state of an organ in
 which the energy of its vital action is  be-
 low the normal type," making it  thus, as
 we have done,  synonymous with debility.
 Roche (Diet, de Med. Prat.  III. 593.)
 gives it a similar definition, and includes
under it the debility from old age, that re-
sulting from venereal excesses, suckling,
profuse suppurations and  secretions, pro-
longed hemorrhages, insufficient alimenta-
tion, the exhaustion of the organs from ex-
cessive action, and finally, from marasmus,
anesthesia and  anemia;  whilst  Littre
(Diet, de  Med. 2d ed. IV. 241.)  restricts
its signification to the " diminutions of the
organic actions without either antecedent
or concomitant  appreciable lesion  of the
solids or  liquids;" and especially  insists
upon the necessity of distinguishing from
asthenia the debility which  follows ane-
mia,  profuse hemorrhages or secretions,
that which accompanies  typhus,  scurvy,
purpura, &c.
   As we  propose under another head (see
Debility) to investigate fully this interest-
ing  subject  it  is unnecessary at present
to expose more fully  the  views  of the
writers we have quoted, or to inquire into
their justness.                    I. H.
   ASTHENIC.  Appertaining to asthe-
nia.                             I- H.
   ASTHMA. (From om or ojnui, I breathe,
or  rather, aauo£u,  I breathe with diffi-
culty.)    Aa9(.ux, Gr.;  Anhelatio,  Lat.;
 Asma, Ital.; Asthme, Fr.; Die Engbrust-
tigheit, das keuchen, Germ.
   Difficult breathing,  which constitutes
the  most prominent feature of this dis-
 ease, seems to have  attracted medical at-
 tention from the earliest  antiquity. The
Greek writers,  as we learn  from Celsus,
distinguished it according  to its grada-
 tions,—calling  it when  moderate, dysp-
 noea—when more  severe,  asthma—and
 when of the utmost violence, orthopnea.
 In the progress of time,  these terms  un-
 derwent  considerable fluctuations in their
 meaning and applications, till finally that
 of Asthma was made  to embrace every
 case of embarrassed respiration, whatever
 might  be its  nature, or the manner in
 which it was induced.  But  this  condition
 presents such  infinite varieties in these
 respects, that a more precise and limited
 definition was  required.  Later authori-
 ties, therefore,  restrict its use to a pecu-
 liar  form of this affection,  recurring in
 paroxysms, each of which,  having a quo-
 tidian  aggravation,  coming on  towards
 evening,  or in the  night and  subsiding
 in the morning, usually with more or less
 expectoration.
   The  symptoms of the disease may be
 divided into such as precede or attend a
 paroxysm.  Most writers agree in repre-
 senting a disordered state of the stomach,
 or some of the  collatitious viscera, as pre-
 liminary to an  attack,  expressed, usually, 
508                         ASTHMA. (Symptoms.)
by  distension of  the prima? viae,  from
flatulence with  sour eructations, gastro-
dynia, cardialgia, constipation,  and ten-
derness of the abdomen,  painfully felt on
going to stool.   But, though general, this
state does not,  at least  in  any very con-
spicuous degree, universally prevail. Cases
I have seen, where there was  an entire
exemption from it, or so faintly presented,
as scarcely to attract attention.   As pre-
cursory of an attack, however, there may
be nearly always remarked, uneasiness of
the head and of the eyes, drowsiness, las-
situde, fulness of the stomach and bowels,
borborygmus, and discharges of wind, with
heaviness of breathing,  stricture of the
chest, precordial anxiety,  depression of
spirits or irrascibility of temper, and a
general feeling of uncomfortableness, all
which, are  more sensibly experienced in
the evening.
  In this state, the  patient may go to bed,
with the anticipation of an  attack, which
shall  come  on  while still awake—or he
falls asleep, out  of which he is aroused at
once, or for a few minutes seems to be be-
wildered by a  sort  of incubus, half con-
scious of his situation, though  unable to
command self-possession.  The  paroxysm
is mostly announced with an  increased
sense of thoracic tightness and oppression,
without any acute  or positive pain, soon
followed by difficult laborious, and wheez-
ing respiration, in which the muscles sub-
servient  to  that process appear to be im-
plicated, attended usually at first by  a dry
spasmodic  cough,  though  ultimately by
copious secretions  of phlegm or mucus,
resembling the sputa in bronchitis.  The
distress is aggravated by motion, and so
much by the recumbent  posture,  that in
many cases, it cannot be endured at all,
or only for a short  period.  The  circula-
tion is commonly  little  affected, some-
times preternaturally weak,  the cutaneous
surface cold, the countenance pallid and
haggard:  but  in other, though  compara-
tively rare instances, it  is  full, vigorous,
and decidedly febrile—the skin warm, the
face flushed and tumid, the  eyes protube-
rant and  injected, with  dryness  of the
nostrils and fauces.   This is the  asthma
plethoricum of  some of  the  nosologists.
The paroxysm being of extraordinary vi-
olence, from the obstruction of the  bron-
chi or pulmonary circulation, the  counte-
nance has a purple  hue—and such is the
degree of anhelation, that to prevent suf-
focation,  the patient  is  propped up, and
exposed to the  fresh air,  by the opening
of doors and windows, he feeling,  as it
were, "as if the room were too small, and
too confined, for his breathing."
   An attack  continues for several hours,
or during the greater portion of the night,
progressively mitigating  towards  morn-
ing.  But, with thi6 abatement some un-
pleasant sensations of the head, chest or
prima? viae, or all, still remain throughout
the  next day, and, on the approach of
evening,  or towards midnight there is a
repetition of the paroxysm.  It is in this
manner, that  with  alternate  remissions
and exacerbations, the case proceeds for a
time, generally not more than three nights,
till  it is relieved by our remedies,  or, as
oftener  happens, expends itself by some
critical  discharge, perspiration, urination,
and especially by expectoration of digest-
ed mucus.  The individual may then be
restored to his natural health.
   Death  rarely occurs  in the  paroxysm,
and when it  does, we  shall find imme-
diately  to precede it, a most distressing
anhelation,  frothing of the mouth,  livid
countenance,  a weak tremulous pulse, or
total failure  of  it,  great depression  of
general strength, and sometimes, more or
less paralysis of the upper extremities.
   Becoming chronic, asthma may termi-
nate in  some disorganization of the lungs
or heart or great blood-vessels, or of tlip
abdominal viscera,  followed by dropsy of
the  cavities  of the chest or abdomen, or
by diabetes, and occasionally in lesions of
the brain or nerves.   But it also endures
without  such degenerations, and the per-
son attains even to old age, with tolerable
comfort—while,  in  medium  instances,
where no essential structural  injury ex-
ists, his health becomes greatly impaired,
and he lingers out an existence of com-
plicated wretchedness, till the disease un-
dergoes  a fatal  exasperation,  or  he is
otherwise released by death.
  In the  recurrence  of asthma,  there is
much difference, though generally, it does
not  observe very strictly the  law of pe-
riodical  movement.   Examples  are re-
corded of its renewal on an average week-
ly,  monthly, annually, or even at a more
distant period, once or twice, for instance,
in the course  of a long life.   But some-
times it is more exact  in its repetitions.
Thus, Heberden relates a case of the re-
turn of the  paroxysm every seven years
for six successive periods, and several are
reported of  a monthly  reversion,  with
perfect precision.  This is what I consider
to be genuine asthma contradistinguished
from other forms of anhelation, of a more
continued character, hitherto very impro- 
ASTHMA.  (Etiology.)
509
perly confounded with it.   That the dis-
ease may in time lose its peculiar feature
of periodicity  is undoubtedly true.  But
then it parts  with its primitive identity
and assumes a new shape, dependent  on
causes entirely different, disorganizations
of structure in the lungs or remoter parts,
which impede respiration, and otherwise
imitate asthma.
   In reviewing the etiology of asthma, it
will not be easy to separate  the remote
from  the exciting causes, with distinct-
ness or propriety.   The predisposition to
it has been supposed to be intimately con-
nected with  a peculiar  conformation  of
structure, consisting mainly in a narrow
ill-shaped chest or contracted larynx, tra-
chea, or bronchi, with a temperament of
extreme sensibility.   But I have seen the
disease so frequently without any such
peculiarities, that I do not think they can
exercise any considerable influence in its
production.   As to temperament, espe-
cially, I am persuaded it is as often inci-
dent  to  the phlegmatic, and  perhaps the
sanguine, as to the nervous.
   That  asthma is hereditary, cannot be
doubted,  and  even  to some  extent de-
scending from generation  to generation,
and pervading a  family of children—of
which, examples  have come  under my
own observation.  On what the transmis-
sion depends, is not at all intelligible—
most probably,  however, on  a constitu-
tional  similarity, though this is sometimes
so little apparent that it must be  rather
assumed than demonstrated.
   Not much can be ascribed to age or sex
in the development of susceptibility to the
disease.   Contrary to the  prevalent opi-
nion,  that it  mostly occurs in the middle
of life, I have certainly met with an equal
number  of instances in children, or prior
to the season of puberty,  and scarcely
fewer among old persons.   Nor  have  I
discovered any marked difference  in this
respect, between males and  females, and
cannot help suspecting the  accuracy of
estimates leading to an opposite conclu-
sion, particularly that of Frank, of Vien-
na, which makes  the  liability of the for-
mer as six to one.  Not unlikely this error
has proceeded from a loose generalization
of affections which,  however analogous
in some of their features, were still not
of a real asthmatic nature.
   From a deficiency of authentic informa-
tion, it is not easy to appreciate justly, the
influence of station, habits, and occupa-
tions,  in this case.   But according to my
own experience, the sedentary, indolent
and luxurious  of the higher orders of so-
                  43*
ciety, are infinitely more disposed to the
disease, than the reverse, or the low, the
active, or labouring classes.  It is, indeed,
seldom to be met with in such, unless en-
gaged in operations in which some acrid
effluvia escape,  irritating the respiratory
apparatus.
  Nearly an equal degree of uncertainty
prevails  as to the tendencies of climate.
The common notion, however, is, that the
disease  is of less frequent occurrence  in
the mild and equable than in the variable,
or in either extreme of latitude, the hy-
perborean or torrid regions, and which is
not  improbable,—though I confess that I
have not remarked any material differ-
ence in the effect of our so diversified
seasons.  Every condition of weather oc-
casions it,  the hot and the cold,  the wet
and dry, or a dense or rarefied atmosphere
—and such is its capriciousness, that what
proves favourable to one  individual, is as
adverse to others.  But independently of
the sensible states of the air, there would
seem to  be some occult quality belonging
to it, that is more decidedly operative on
the asthmatic constitution.   The pure air
of the country, especially in elevated po-
sitions,  I have  found, with very few ex-
ceptions, more  pernicious  than  that  of
cities, and even the suburbs of these less
propitious than  the central  and populous
parts.  Many instances have come under
my own view,  of persons affected in this
way, who, very  comfortable  in the latter,
were rendered  otherwise  in the  former
situation, among which, is that ofa friend
of mine, who can seldom walk to the edge
of the city with impunity, and never goes
into the country without an attack.
   Moreover, positions nearly contiguous
in the heart of a city, may vary widely in
this respect or even the several stories of
the  same  house.  Each  of these  state-
ments,  at  least is verified  by one case
which was the subject of my care.  Called
to visit a young lady from the South, hav-
ing a violent paroxysm of the disease,  1
was  told that she derived an immunity
from it during a recent residence in Pa-
ris, by selecting a  medium story in  a ho-
tel in a particular portion of that city, and
that whenever she quitted the apartment,
a paroxysm  soon came on, from which she
was as speedily relieved by returning to
it.   Curious to  make the experiment, I
was seconded in the desire, by her own
anxiety  to  change her  lodgings, where
she  had severely suffered, and in a very
short time she  went  to another house in
the  neighbourhood, in which she entirely
escaped  for several months.  Compelled, 
510                          ASTHMA.  (Etiology.)
however, to leave it, she fixed her abode
at the distance of a few hundred yards, in
a street no less thickly built, and here she
had  scarcely any exemption  for weeks.
On her moving into a different quarter of
the city, I witnessed a complete verifica-
tion of the statement  she had made  me.
As long as she occupied the chamber on
the second floor,  she was almost nightly
harassed by renewals of attacks, which
were prevented by her sleeping  in  the
room above.   Even by dining below,  her
respiration was on several occasions seri-
ously affected.
  Among the causes  obviously exciting
the disease, may be enumerated, the in-
halation of the fumes from lead, or ar-
senic,  or mercury, or other minerals, or
the smoke of tobacco, or the dust of the
same  article, or the  pungent or fetid
odours  or luscious perfumes, emitted by a
great number of flowers or substances, as
the  rose, the hyacinth,  fresh hay,  red
beets, mellow apples, sealing-wax,  musk,
and  particularly ipecacuanha.   Examples
of attacks to be traced to each of these
sources are reported, and as regards seve-
ral of them, my own experience has sup-
plied me with further proofs.
  In an individual whom I attended,  the
disease was twice brought on by sleeping
in a room where a  rose-bush in  bloom
was placed—in  another,  by a similar ex-
posure to some pots of hyacinths—in three
girls, by the emanations in the process of
manufacturing cigars—and there was for-
merly a student  of medicine in the Uni-
versity  of Pennsylvania, who assured me
that he could not weigh out a  dose of
ipecacuanha without being affected. Cer-
tain irrespirable gases, as carbonic acid,
escaping from the chimney of a dormi-
tory, is said to have had the same effect
under like circumstances.
  Most or perhaps  all of the preceding
causes  operate directly on the pulmonary
organs, to which are to be added,  such as
affect  them secondarily or by irritations
transmitted  from other parts of the sys-
tem.  Thus it has been known to proceed
from worms or offensive ingesta, even in
moderate quantity, or excess in eating or
drinking,  or  inanition from long fasting
and  constipation of the bowels.   Deriva-
tive impressions, indeed, from the whole
of the  abdominal viscera, and above  all,
the uterus, as manifestly induce it,  and
we shall presently see that still more is
imputed to  lesions of the thoracic con-
tents.
  It were  well,  had  a closer attention
been directed to the influence of spinal
irritations in the production of the disease.
Cases  having unequivocally a location in
the upper portion of the vertebral column,
I have so repeatedly seen, that I am per-
suaded of its being a more common origin
of it than heretofore suspected.
  Entertaining the notion of the frequen-
cy of the disease from the repercussion of
eruptions,  asthma  exanthematicum  has
been  erected into  a distinct species in
some of  the nosological  arrangements.
But in consequence of  the permanent
character of the affection, when in this
mode induced, it seems to me  doubtful,
whether it should not be considered rather
as  dyspnoea, which,  in the present  ac-
ceptation of the term, is continued oppres-
sion, and  not intermittent  or paroxysmal,
than genuine asthma. Nevertheless, though
they may not come within  the definition I
have given of the disease, I cannot with-
hold the communication of some very in-
teresting instances of the kind, I  have met
with.
  The  first of these, was  that of a gen-
tleman who having repelled a wide-spread
tetter from  the inside  of  the thigh, was
soon after seized with the  most  afflicting
anhelation, which  continued  with  little
remission, for  nearly  a  year,  resisting
every variety of treatment, till the reap-
pearance  of  the  tetter, when relief was
procured.
  Even more extraordinary, was that ofa
man, who having the same sort  of erup-
tion on the scrotum, succeeded, as he sup-
posed,  in  curing it.  But almost immedi-
ately afterwards, he began to sneeze with
scarcely any interruption  by day or by
night for several months.   The irritation,
however,  being transferred from  the nasal
to the pulmonary tissue, was followed by
an  exchange of sneezing  for a  very op-
pressed state of the lungs, which  for a
length of time proved  intractable to all
remedies. Two days after consulting rne.
and before the treatment suggested could
have had any  effect the  tetter, sponta-
neously, as it were, replaced itself in itd
original position, and his  health was re-
stored.
  Nearly about the same period,  I  had
under my care a lady, for a scaly eruption
on  the  back of the neck, extending  into
the hairy  scalp,  by which  she was  mucli
annoyed.  It had long  existed,  occasion-
ally receding and again recurring.  By a
mild application,  it speedily disappeared,
and in  the course of a few months showed
itself on the forearm, gradually  assuming
a more scaly  character.  In this state, she
left the city, and,  as she presumed, was 
ASTHMA. (Diagnosis, Prognosis, and Autopsy.)
  cured  of it  by another  physician.  But
  from that moment, heavy dyspnoea super-
  vened, which shortly proved fatal.
    Nor  are  we without  proof of similar
  consequences from the suppression of na-
  tural or habitual  discharges,  sometimes
  proceeding  from amenorrhcea, or a stop-
  page of hemorrhoids—and  Andral has
  supplied us with  a case  ascribed  to the
  healing of an old ulcer of the leg. It may
  also be  owing to  a metastasis  of some
  other  diseases, as  rheumatism  or gout
  especially.   The  late Professor Barton,
  who was a victim to the irregular states
  of the latter disease, I have seen to suffer
  extremely from asthma, thus occasioned—
  and still more frequently, a friend, whom
  I have attended in more than one hundred
  similar attacks in  the  last twenty-five
  years.  Coming on in him almost invari-
  ably in this way, gout will so continue for
  a few days,  when  usually fixing  itself on
  some joint, the whole of  the thoracic dis-
  tress immediately ceases.
     Besides this series of physical agen-
  cies, it is perfectly ascertained  that the
•  disease may be excited by certain moral
  emotions, as, the exasperation of rage, the
  agitation of fright, the impulse of joy, the
  depression of grief, &c,  where  there  is
  extreme affectability in this respect.  But
  in thus spreading out its etiology, I am
  very far from being satisfied, that in all
  instances, I have  practised a just discri-
  mination in the selection  of the causes of
  asthma. Confiding too much in authority,
  as well as from inherent deficiencies, I do
  indeed apprehend, that I may have some-
  times fallen into the common error of con-
  founding very different affections with it,
  and particularly bronchitis, and other mo-
  difications of dyspnoea.
     Diagnosis.  As  I  have  described  it
  asthma  can  scarcely be  confounded with
  any other disease.  The suddenness of its
  paroxysms,  their  entire  subsidence, and
  periodical recurrence, with the severity
  and peculiar nature of the breathing, suf-
  ficiently distinguish it for the most part.
  The cases which bear the nearest resem-
  blance  to it,  are bronchitis, pulmonary
  (Edema, hydrothorax, some  of the affec-
  tions of the heart as angina pectoris, and
  certain dyspeptic states.  To discriminate
  it  from these, where a comparison  of
  symptoms fails, an appeal may be made to
  external exploration, though not much is
  positively gained  by either percussion or
  auscultation,  in pure uncomplicated asth-
  ma.  But the utility of these means con-
  sists in the detection of other analogous
  affections having more definite signs, and
                                   511

thus, while showing that the case is not
asthma, its real nature may be revealed.
  Prognosis. Contracted early in life, in
well-constituted individuals, or where ex-
cited by trivial or transient causes,  it is
generally a curable disease.  As to the
former, even if our remedies do not eradi-
cate it, time, and the changes of puberty,
will be apt to effect it.  But  occurring in
more  advanced age, or with a contracted
ill-formed chest or as an  inheritance, or
continuing till organic lesions take place,
we shall rarely be warranted  in pronounc-
ing a favourable decision. It is here " mor-
bus maxime terribilis," as it was origin-
ally called by Willis.
  Post-mortem appearances.  Dissection
has disclosed very different  phenomenon
in asthma.  The fact is,  till recently, we
had no precise view of the  disease, and
hence  most  of the reports of the anato-
mical characters are little to  be trusted—
these  belonging, in many instances, to or-
ganic  lesions of parts,  of which the re-
spiratory  affection was  merely an in-
cident or perhaps wholly independent  of
them.
  No trace of a morbid process can some-
times be discerned, in the lungs,  or  else-
where. This had  long been affirmed, and
is now established by the concurrent tes-
timony of Corvisart, Laennec, Andral,
Bouillaud, Cruveilhier,  Leroux,  Fer-
rus, &c.   Death  here, is  probably occa-
sioned by spasm.   But generally, there is
phlogosis of the  mucous  lining of the
lungs, diffused or in patches, or merely
punctated, attended  most frequently  by
exuberant secretions. There are instances,
however, of a great deficiency in this lat-
ter respect,  and then tumidity of the tis-
sue exists. Nor would it seem, that either
their  substance, or pleural coverings, al-
ways escape congestion or inflammation—
and occasionally oedema or emphysema of
the  cellular  texture,  together  with  a
change of colour or softening of the brain,
or effusions into it,  have been  remarked.
Cases, however, are reported, in which
the only appreciable  lesion was of the
nerves—in  one  of these, at the origin of
the pneumogastric, the precise  nature  of*
which is not mentioned,—in  a second,  an
ulcerous  condition of it,—in a  third,  a
small tumour along its course,r—and in a
fourth, an osseous  deposition in the centre
of the pulmonary  plexus.
   But in protracted and  long-continued
asthma,  as  might be expected, from the
complications and degenerations to which
it is liable, every species of disorganiza-
tion has  been  met  with, as well of the 
512                         ASTHMA. (Pathology.)
thoracic as abdominal viscera especially,
and which is shown to be the tenor of ap-
pearances from the time  of Morgagni,
Bonetus,  and Lieutaud, down to that of
Baillie, and Rostan, and other very re-
cent cultivators of morbid anatomy.
  Pathology.  Notwithstanding these ne-
croscopic  reports, very little seems to be
distinctly understood as  to the pathology
of asthma.  It were  a very unprofitable
task to offer a retrospect of the  idle  con-
jectures or  crude speculations  of early
times, in relation to  the  subject, and I
shall hence decline it.  Cullen, and most
of the more modern writers,  suppose  that
the disease  consists in a spasmodic  con-
striction of the  muscular  fibres of the
bronchi, which interrupts  or disturbs re-
spiration,  and as a consequence, creates
all  the  rest of the distressing symptoms.
These fibres, not having been shown,  it
was deemed at the time, a fatal objection
to the hypothesis.  But since the satisfac-
tory investigations of Soemmering, Cru-
veilhier, and especially Reisseissen, who
have demonstrated their  existence  both
transversely and longitudinally as regards
these tubes,  it can no longer be alleged.
Bree, however, contends, with some in-
genuity, that in the  leading, and most
common form of the disease, the imme-
diate cause is irritation in the air cells of
the  lungs,  occasioned either by aerial
acrimony or effusions of serum, here plain-
ly mistaking the effect for the cause, at
least in one of  these cases.  Every prac-
titioner must have observed, that in what
is called spasmodic  asthma, particularly,
the dyspnoea occurs long  before  the in-
creased secretion  of the mucous surface.
  Denying  that spasmodic asthma  is a
disease  of the  lungs,  it is conjectured by
Wilson Phillip,  that its seat  is in the
upper part  of the windpipe, which be-
comes contracted by spasm of its muscles,
so as to prevent the  ingress of air,  and
brings on the violent struggles for breath,
characteristic of the  paroxysms.  Cases
answering to this description, I have seen,
though  the affection of the larynx has ap-
peared  to me  merely additional  to the
more general one of  the  bronchi, and at
all events, from their rarity, ought to be
held as  anomalous occurrences.
  The  phenomena  of the disease have
been ascribed,  by Parry,  to vascular en-
gorgement of  the  mucous lining of the
bronchi, productive of such a degree of
tumidity of it,  as mechanically  to inter-
cept the entrance of the air into the lungs.
This may be sometimes the fact though I
suspect such  a condition  is  always se-
condary, and consequential on antecedent
spasmodic irritation.
  By his autopsic  inquiries,  M. Rostan
has been led to the inference, that the dis-
ease, never nervous or spasmodic, depends
on an  organic lesion of the lungs, heart,
or large vessels.  But such a notion, how-
ever correct as to some varieties of dysp-
noea, cannot  be  sustained  in  its applica-
tion to genuine asthma.  This, as we have
seen, not unfrequently makes its invasions
suddenly, and disappears,  leaving for an
indefinite period an  uninterrupted state
of health—is re-excited by slight circum-
stances,  and relieved by remedies which
can have no  control over the organic le-
sions alleged, which indeed,  have been
proved, sometimes,  not to have  existed.
Most of the speculations on this point are
marked by extreme vagueness. Dyspnoea,
however induced, or whatever might be
its particular nature, having long received
the title of asthma, the most discrepant
affections were held  to be identical, and
described accordingly.  By the same want
of discrimination, I apprehend, the writer
just cited has been seduced into the adop-  •
tion of such  an erroneous hypothesis.
  It appears to me highly probable, that
asthma is essentially an affection of the
bronchial structure, in the shape of spasm.
The phlogosis, effusions, and other morbid
phenomena  occasionally observable, are,
according to this view, to be considered
merely as  results  of this pre-existing
spasm.  Careful observation, however, will
lead us to consider some of the spasmodic
movements, hitherto referred  to the bron-
chi themselves, as actually existing in the
upper  portion of the trachea, or in the
diaphragm, intercostal and other muscles
subservient  to the  respiratory function.
As  the muscular  apparatus in vomiting is
excited, when the stomach is offended, so
is that of the pulmonary organs,  to dis-
charge  or overcome irritations  in the
lungs,  and may, in  their efforts  to this
end, become  irregular and disorderly  in
their actions.  Either spasm of the bron-
chi, or excessive secretions from their mu-
cous surfaces, or  both,  are  the direct
causes of such  endeavours in the asth-
matic paroxysm.  But on other occasions,
it may be perceived, that the chief aim
of the muscles of respiration, is to dilate
the  chest, so as to  allow greater freedom
to the admission of air, and  in the per-
formance of this office, are often more na-
turally exerted.
  It is not  unlikely, I think,  as has been
conjectured,  that the immediate seat  of
the primary irritation, in many instances 
ASTHMA.  (Treatment.)
513
of this disease, may be the pneumogastric
nerves.    Looking  at their  distribution,
several of the most prominent of the  af-
fections of the case, become very explica-
ble on such a supposition.   Granting this,
it is no less  apparent to me, that it does
also arise occasionally in any one section
of the nervous system.  That I have seen it
  froceeding from the spinal and ganglionic,
  am  as well assured as of any fact. Nor
when we advert to the intimate connexion
of the nerves from every source, is there
any difficulty in the hypothesis.   It may
be deduced from all which has been said,
that I consider asthma as originating in
nervous irritation, soon productive of ir-
regular spasmodic  movements, often fol-
lowed by  inflammation of the pulmonary
tissues and  excessive secretions,  which
condition, not being arrested,  it may lead
to very serious  and multiplied lesions of
structure.
   From  the very  indefinite notions  of
asthma, to which I  have more  than once
alluded, as having  prevailed, the  disease
has been  separated into a great number
of  species or varieties.  By Sadvages,
eighteen  are made, and he scarcely ex-
ceeds some other writers. But this surely
is a minuteness of classification, not war-
rantable by the nature of the case, and is
calculated rather to perplex,  than to illus-
trate the management of the disease.
   The ordinary division of  asthma,  and
that usually adopted, is into spasmodic
and humoral—the one being dry, and the
other attended with profuse secretions,
the first mostly incident to the early,  and
the second, to the advanced period of life.
Even these  two forms of  the disease,
though occasionally observable, have no
specific character, and cannot claim to be
nosologically distinguished.   The  differ-
ence between them seems to depend only,
as in the  instance of common catarrh, on
a secreting  or  non-secretory state  of the
mucous surface of the lungs, each  of
which mostly takes place too, in the pro-
gressive stages of the same  case.
   Treatment.   Whatever  pathological
views may be entertained, the treatment
arranges  itself into  such  as is  proper
during the paroxysm, and  in the inter-
val,  to retard or prevent  its  return,  or
in other  words, to  eradicate the disease.
It is necessary to premise, that I shall ap-
ply my remarks only to its curable state.
Disorganization  having taken place, the
case changes its character,  and  may be
deemed  hopeless,  or demands  another
course for its relief.
  Contemplating merely the  prominent
symptoms of such an attack as I have re-
ference to, no practitioner would hesitate
probably a moment, about the propriety
of venesection.  It seems to be called for,
by the congestion  of the lungs, by the la-
borious respiration, by the  suffused coun-
tenance, sometimes by activity of the cir-
culation, and by a variety of other consi-
derations.  Yet it is confessed, that the
remedy is an ambiguous one, and while
by many it is utterly condemned,  even
those who occasionally recur to it, allow,
that the advantages derived, are not at all
correspondent to what might be expected.
My conviction, however, is, that  though
our anticipations from it  may not be re-
alized in the fullest extent, venesection in
the more violent paroxysms is useful, and
even indispensable.  As a general  rule, it
should be restricted  to the  febrile cases,
or where there  is much general vascular
disturbance, and here,  it will be found, or
I am greatly deceived, to abate the vehe-
mence, as well as shorten the duration, of
the  paroxysm—and  most  indubitably, it
obviates those  injuries of the lungs and
other structures, which lay the foundation
of the chronic lesions of which I formerly
spoke.  Cases, however, occur, where ve-
nesection is  inadmissible,  though there
may be present no inconsiderable pulmo-
nary oppression.   It is in this state, that
topical depletion is indicated, and may be
beneficially employed. As in nearly every
other pectoral affection, however, the blood
should  be drawn from the back  of the
neck and between the shoulders.   Taken
from these parts, it is  generally more ef-
fectual, and becomes indispensable, should
there be irritation of the upper portion of
the  spine.  The chief exception  to this
practice is to be found in the dependence
of the case on  a primary or predominant
affection of the ganglionic  nerves,—and
here it answers better from the breast and
epigastric region.  Exactly the same pre-
cept  is to be  observed in the application
of blisters, to the neglect of which, much
of the contrariety of sentiment which pre-
vails as to their utility, may be ascribed.
   Greater unanimity perhaps exists in re-
gard to emetics than any  other remedy.
Most  of the  older  writers  urge them
strongly, and the same recommendation
of them has been generally continued to
the present times.  But some are opposed
to the practice, as hazardous or altogether
inefficient—though for reasons so frivo-
lous, that so far from being influenced by
them, I habitually prescribe vomiting  in
the  paroxysm,  and very frequently with
marked  success, especially in children. 
514                         ASTHMA.  (Treatment.)
The nature of the case  should not mate-
rially influence us.   Whether to resolve
spasm, or to remove vascular congestion,
or to empty the bronchi of excessive se-
cretions, or to act on the skin, it is equally
serviceable.  Confessedly of the highest
utility in croup and bronchitis, why should
it prove otherwise in a case so analogous
to these affections ?   Generally, the ipe-
cacuanha is> here  preferred, which I be-
lieve was  originally  proposed  by Aken-
side, the physician and poet.  The squill,
however, has been greatly praised, and it
is not at all unlikely, that it is well suited
to the disease, and especially when it oc-
curs in old people, whose lungs are mostly
oppressed,   and  hence   require  to  be
emulged or  unloaded, by an emetic ac-
tive and stimulating.  Much, too, has been
said,  of the increased value of the  com-
bination of the  two  articles.  The sul-
phate of zinc, moreover,  is not without its
advocates, among whom was the late Pro-
fessor Kuhn, who  employed it in this, as
well as in every other spasmodic affection
of the lungs, or their appendages, from a
conviction  of its  superior  antispasmodic
properties.
  Emetics, in nauseating doses, are,  by
some, preferred to active vomiting,  and
the comparative utility of the two modes
seems not to be  satisfactorily determined.
To me, however,  it is clear, that the one
or the other, in this, as in all other  in-
stances, is to be directed according to the
stage and  circumstances of the disease.
To break down the attack, as it were, vo-
miting  is infinitely more powerful, while
in reference to the expectorant or diapho-
retic effect the nauseating doses answer
better.  Commonly,  the ipecacuanha  is
given for this purpose.  But in old people,
the more stimulating expectorants will be
demanded—the squill, the syrup of garlic,
the  assafetida, the gum ammoniac, the
seneka, &c.
  Many practitioners speak favourably of
the  tincture of the Lobelia inflata,  and
some extravagantly—with  which I have
no  experience.  But I think I have seen
the juice or tincture of the berry of the
Poke, Phytolacca Decandria, decidedly
serviceable in one case,  and I have heard
much of its  efficacy.
  No great importance is attached to pur-
gatives in the treatment of asthma.   Be-
ing  induced, however,  by  constipation,
this condition, at least should be removed.
But there  are other  purposes  to be met
by purging.  Certain it is, that I have de-
rived advantage from the use of calomel,
especially, as well as an evacuant of the
bowels, as by the property it possesses of
unloading  oppressed  lungs  proceeding
from undue accumulations of blood or vis-
cid secretions, it being, in the latter view,
a very efficient expectorant
  Nothing seems to be more  reasonable,
from  the received  notions of the nature
of the asthmatic paroxysm,  than that opi-
ates should be  of service in it, and they
have accordingly been liberally prescribed.
Bree, a writer on  the  disease, whom  I
formerly cited,  says,  however, that they
are uniformly hurtful—and such is not  a
rare opinion.   The truth is, that the ef-
fect of them varies  at different stages of
the paroxysm,  they being always misap-
plied, I suspect iu the height  of it  But
it being in part subdued  by the preceding
active means, opiates, then, are very ser-
viceable,  and especially when combined
with a diaphoretic, as in the Dover's pow-
der.  The state of the skin has, indeed,
I suspect, been not sufficiently regarded
in  the treatment of asthma.   But when
we advert to its influence over the lungs
in health and disease,  it  becomes obvious
how important it must  be  to revive or
promote  its action.  On the breaking out
of perspiration, warm and diffused, I have
usually found a very  decided alleviation
to accrue.
  Not content with opiates alone, every
article allied to  this class, including the
narcotics and antispasmodics, cicuta, hy-
osciamus,  belladonna, musk,  assafetida,
ether, &c., has been  successively tried,
singly, and variously combined.  What I
have said in relation to opiates, is equally
applicable to their  congenera, with this
difference only, that I believe the whole
of them  are of inferior pretensions.  The
best opiate merely to calm irritation,  is
the elixir paregoric, and especially when
the disease  occurs in  aged  people,  to
whom it is peculiarly well suited,  in this
and every other  pectoral affection.  Yet
disagreeing with  the patient  the pure
opium, or some other of its preparations,
may be tried, as well as the kindred arti-
cles mentioned.
   During the paroxysm,  an alleviation  is
sometimes procured by drinking intensely
cold water—and,  in other  instances, by
sipping hot water, or other hot beverages,
such as very strong coffee, without cream
or  sugar.  Exposure to cold air is also
beneficial, though sitting near a fire, with
the feet applied to it, still more frequently
is found  effectual.  Large  doses of the
fixed  alkalies  have been recommended,
and there is much evidence to the efficacy
of vinegar freely given.   Let there be no 
ASTHMA.  (Treatment)
515
surprise  at my mentioning such opposite
remedies!   This is not the only disease,
where means, diametrically the reverse
of each other, are found serviceable,  and
which we employ without the usual guide
or reason.   It may be  humiliating to the
pride of science, though it is indisputably
true, that often in practice, we are com-
pelled to throw all our boasted principles
behind our backs, and trust alone to the
lessons of experience, in the spirit of em-
piricism.
   To  relieve the lungs when oppressed
by inordinate secretions,  inhalations  of
vapour are obviously pointed out and have
been recurred to in many instances, with
success.  Even the steam of water is not
without  utility,  though it may be  im-
proved by those medications to be detailed
under the head  of Bronchitis.   The va-
pour of iodine and of  chlorine  has also
been lately proposed.
   It was at  one period in the reign of
pneumatic  medicine,  very much the fash-
ion to use, with this design, the factitious
airs.  Consulting the  reports of Beddoes,
Thornton, and  others, on the  subject  it
will be perceived,  that these  gases  are
most enthusiastically  praised.   By one of
them it  is  affirmed, "that the  effect  of
oxygen is altogether miraculous—the mo-
ment it is inspired, the  livid colour of the
countenance  disappears, laborious respira-
tion ceases,  and the  functions of all the
thoracic organs go on easily and pleasant-
ly."  But subsequent and  more faithful
trials have proved that no such benefit ac-
crues, either from oxygen, or any one of
the  irrespirable gases, alone,  or united
with atmospheric air; and this suggestion,
like many other  similar  extravagances
which have had  an ephemeral existence,
is dead, and gone to the " tomb of all the
Capulets."
   The insufflation of  the atmospheric air,
is perhaps more entitled to attention.  By
Chiarenti,  an Italian  writer, we are at
least told that he himself is uniformly re-
lieved almost instantly by  it and that  it
has proved equally successful in other per-
sons by whom it has been tried.  The pipe
of a common bellows  is to be introduced
into the mouth, the nostrils closed by com-
pression  of the fingers, and the  air to be
forcibly pushed into the lungs.  (Antholo-
gia di Firenze, Sept. 1835; and Philada.
Journ. Med.  and Phys. Sc. XIV. 374.)
  Being, in some degree,  a  modification
of the practice of inhalation, the smoking
of certain substances, and partially breath-
ing the fumes, may be here noticed.  My
allusion is  more  particularly to the stra-
monium, which has attracted a great deal
of notoriety as a palliative of the parox-
ysm.   It is used in a common pipe—the
root of the plant selected for the purpose,
being previously washed, dried, and bruis-
ed.  That  it  affords  relief, occasionally,
I cannot doubt,  independently of other
evidence of it  having witnessed  it,  in
several cases. Like other remedies, how-
ever, it will often fail, and, perhaps, only
does good in certain forms of the disease,
which  hitherto have not been accurately
designated.  The cigar, also, proves some-
times palliative,  and especially  in persons
not habituated to the practice of smoking.
Never have I witnessed any injury from
either article, in this application of them,
and am incredulous of the statements  of
the European writers by whom their use
is so seriously deprecated.
  Magnetism, electricity,  and galvanism,
have been adopted  as remedies—and the
reports regarding the last, are very curi-
ous, proving,  that  through the galvanic
agency, the paroxysm is  promptly miti-
gated,  or removed, and by perseverance
in its use,  permanent cures are often ac-
complished.  Not a little is affirmed of  its
efficacy by  Mons. Andrieux, in a recent
memoir on  the  subject, who has pursued
the practice to a great extent—and his
statements  are amply confirmed.   By M.
Martin  it  is said, that he has had fre-
quent opportunities of observing  the ex-
traordinary success  of it, as conducted  by
Andrieux in the Hotel-Dieu, having even
" known patients in whom the paroxysms
were so severe and frequent as to render
it  impossible for them to  engage in any
occupation,  entirely restored to health  by
it in  the course of a few weeks."  He
on  the whole assigns to  it  the  highest
rank among the means  employed in the
disease.  (Martinet's Practice,  p. 110.)
The celebrated Wilson  Philip also bears
testimony in its favour, and  many other
attestations  of the  same kind  might  be
cited.   Conceding the fact of its utility,
which  can  hardly  be controverted, we
must be  irresistibly drawn to the  conclu-
sion, that asthma, as has been contended,
is really little more than a mere nervous
or spasmodic affection.
  We now  come to the second indication,
or to the  treatment in the  interval of the
paroxysms, with  a view to  the eradication
of the disease.  To be at all successful,  it
must be accommodated to the several con-
ditions in which  the system may be left.
These  are   exceedingly diversified,  and
being,  for the most part, connected with
some positive lesion, considered as a dis- 
 516                         ASTHMA.

 tinct affection, to be hereafter fully dis-
 cussed, I shall, at present, give to the sub-
 ject a very cursory notice.
   Mostly, the alimentary canal is  disor-
 dered, and when so, the  management,  in
 every respect is the same as in dyspepsia.
 The  remedies in the latter case will, un-
 der similar circumstances, be found equal-
 ly appropriate to asthma, and above all,
 the martial preparations.  They have been
 greatly  extolled  by Bree, and independ-
 ently of their general power and effects,
 would seem to have further claims in this
 instance, from their reputation  in  those
 nervous affections to which asthma some-
 times bears a resemblance.
   In cases observant with some exactness,
 of the law of periodicity, other tonics are
 resorted to, among which  are the sulphate
 of quinine, the arsenical  solution, the ox-
 ide and sulphate  of  zinc, the sulphate of
 coDDer  and the nitrate  of silver.
   Characterized by a disposition to spasm,
 the  state is  managed by  the valerian,
 myrrh,  musk, castor, assafetida, the oil of
 amber,  ether, &c.—and when nervous ir-
 ritability preponderates, by opiates, hen-
 bane, hemlock, belladonna,  stramonium,
 and the prussic acid.   Being assimilated
 to chronic bronchitis,  the balsamic and
 terrebinthinates, especially the tar pill,  is
 greatly relied on, and which I deem emi-
 nently  useful.  Lastly, on an apprehen-
 sion of effusions, mild  purging,  and the
 diuretics, constitute the proper means.
  It need scarcely be remarked,  that if
 the case can be distinctly traced to a spe-
 cial cause, as, obstruction of the catame-
 nia, the suppression of hemorrhoids, the
 recession of eruptions, or to misplaced
 gout, or spinal or similar irritations, our
 efforts should be directed to its removal as
 speedily as possible, the best  means of do-
 ing which, will be elsewhere  pointed out
 (See the articles  on these affections.)
  Little else remains, than to indicate the
 proper regimen,  to which, in my opinion,
 more consequence should be attached, than
 to the therapeutic treatment.
  As gastric irritation operates as an ex-
 citing or aggravating cause of asthma,  it
 is obvious that the diet must be strictly
 regarded. Even where no dyspeptic symp-
 toms exist some  restrictions  are demand-
 ed in the course of living.  No trespass,
either in eating or drinking,  is ever  to be
 permitted,  and constipation  should  be
avoided.  No  less  important  is   it to
guard against the austere vicissitudes of
weather, by warm clothing, and especially
by wearing flannel next to the skin, pro-
(Treatment.)

 tecting the feet, at the same time, in the
 most effectual manner.
   Exercise, and even labour, are very be-
 neficial.   Long journeys have frequently
 removed  the  disease — and contrary  to
 what  we  might expect the same  effect
 has been  obtained by the exposure and
 hardships  of military life.   During the
 late war,  when the volunteers of Phila-
 delphia were called out and encamped for
 several months, part of the time in win-
 ter, two individuals of my acquaintance,
 who, previously, had been dreadfully ha-
 rassed by the  disease, entirely escaped
 while thus employed, and have since been
 nearly exempt  from it   Many  similar
 facts are recorded.
   The disease becoming habitual, a trial
 of a change of residence should be pro-
 posed.   As, perhaps, in every other pul-
 monary affection, a mild and equable cli-
 mate  is generally to be preferred.  But
 the  p*T€cise situation is to be very much
 determined by the experience of the indi-
 vidual himself,  though, as  already inti-
 mated, for the  most part a low is better
 than an elevated position, and a large city
 than a village or the country,
   Concerning a vicinity to the sea-shore,
 there  is equal uncertainty as to its influ-
 ence.  Commonly, I have found it salutary,
 while  in some instances, it proved so pre-
 judicial, as not at all to be endured. Cases
 will, indeed, occur, where, as soon as the
 individual  breathes such an atmosphere, a
 paroxysm  comes on.  But should an ex-
 posure of  this sort agree  with him, im-
 mense benefit  will  result  from  it and
 sea-bathing.  Not, however, being conve-
 nient or admissible, the  cold bath may be
 substituted,  the efficacy of which if. im-
 proved by  the addition of salt, and subbe-
 quent  frictions,  so as to induce a general
 glow  of the surface.  The  warm  bath,
 which  has been recommended by some
 writers, I have found injurious.
   On  a review of what has been said of
 the treatment of this disease, it is impos-
 sible  to resist the conclusion, that great
 as the  recent efforts have been to reduce
 it to some definite principles, it  is still
 amenable to the charge of empiricism. As
 must always happen, this is owing to the
 want of a  correct  pathology.  It may be
 true, that our notions regarding it are not
 so absurd as those of former times, when
 necroscopic investigations were less  prac-
 tised.   To  the  attainment  however, of
 correct and  useful views on  the subject,
 6iich as shall serve to conduct us to suc-
 cessful practice, much remains to be ac- 
ASTHMA.  (Bibliography.)
517
complished.   As it is, at present, we can
really claim  very  little  certainty in the
management of any stage or condition of
the disease.   The remedies  which control
one case, utterly fail in another, of appa-
rent identity, and hence the number of
expe  ents, and diversities  of plans, that
have  and continue to be  adopted  for the
relief of the disease.
   Considering how limited and precarious
are our powers in this respect it becomes
a duty to enjoin our patients to be vigilant
of the approach of an attack, and the mo-
ment we are apprised of it,  to endeavour
to arrest its further progress, which, com-
paratively, is easily done.   Coming on as
catarrh, it  is in this inchoative stage to be
treated accordingly. Being mild, a stimu-
lating pediluvium,  with  an  opiate  dia-
phoretic, and some warm beverage, will
generally be sufficient,  provided perspira-
tion is excited.   But when the indications
are more menacing, the loss of blood, with
sinapisms to the lower extremities, are re-
quired.   These failing, an emetic of ipe-
cacuanha  should  be directed,  and  after
puking,  the  Dover's  powder,  with  the
usual promotives of its  operation.
   By such a  course, I have in many in-
stances, averted attacks,  and had  the gra-
tification  of preventing  an  intensity  of
suffering which can only be  appreciated
by those who have witnessed the effects
of a severe paroxysm of the disease.
                           N. Chapman.
  Bibliography.—Cousin, (J)  Novum asthma,
novis signis. novam causam arguenlibus defectum-
Paris, 1673.
  Floyer.  A Treatise of the Asthma.  London,
1698, in 8vo.;  3d edit. 1726.
  Ridley.  Observations de asthmate et hydro-
phobia.  London, 1703, in 8vo.
  Gohl.  Umstiindliche Relation eines extraordi-
nairen Casus einer  convulsiveschen Engleriislig-
keit, die  man nach dcm Tode gefunden seltsame
grosse Herzgewiichse.  Berlin, 1710,  in 4to. An
enormous polypus concretion in the heart and
large vessels.                         .  .
  Beck, (J. G.)  Historia  de viro,  palpilatwne
cordis et asthmate  violenlo mortuo,  ejusdemque
viscerum, cultro  anatomico nudatorum mirabih
structura.  Giessen, 1718.
  V'ater, (Ab.) resp. Arnold, (J O.)  Casus sin-
gularis aslhrnatis a depressione sterni ex febre
purpurala,  cum  orthopnaa  afftigenle  reportati,
sola thoracis artificiali cohstriclwne curati.  Wit-
temberg, 1730,  in 4to.  (Hall. Disp. ad. M.  II.)
  Planer, (G. A.) De asthmate sanguineo.  Stras-
bourg, 1737, in 4to.                   ,
  Schulze.  Diss, sistens agroium asthmalicum
usu radicis  scillce sublevatum.  (Hall  Disp.  II.
139.)  Halse, 1737, in 4to.
  Valemtiv. Asthmatis pathologica consideralw.

"■s* us.. * ^syrr**"*


  vol. ii.           44
in Asthmas; in Med. Trans, published by Col-
lege of Phys. in London. V. 93.  London, 1768.
  Vogel.   Progr.  Observationes bina de asth-
mate singulari ex  carlilaginum costarum osses
scientia.  Gottingen, 1773.
  Knell.  Diss, de asthmate theoretice et pralice.
Edinburgh, 1784, in 4to.
  Withers, (Thom.)  Treatise on the Asthma,
&c.  London, 1786, in 8vo.
  Ryan, (Mich.)  Observations on the history and
cure of the asthma, in which the propriety of using
the cold bath in that disorder is fully considered.
London, 1793, in 8vo.
  Bree, (Robt.)  A practical inquiry  on disor-
dered respiration, distinguishing the species of
convulsive astlima, their cause and indication of
aire.  Birmingham, 1797—5th edition, London,
1818, in 8vo.
  Franseri.  Memoria  sobre una difficuldad de
respirar.   (Acad. Real. Mad. I.)  Madrid, 1797.
  Lipscomb, (G.)  Observations on the history and
cause  of Asthma, with a review of Dr.  Bree's
Treatise.   Birmingham,  1797, in 8vo.—Ibid. Ob-
servations on Asthma, and the cause of it proved
to depend on acidity in the system. London, 1805,
in 8vo.
  Wolf.  Bemerkungen uber  das Asthma,  in
Hufeland's Journal, XVIII. 9-86.
  Aubert.  Diss, sur Vaslhme considiri comme
maladie nerveuse.  Theses de Paris, 1809.
  Zalony.  Traiti de Vasthme.  Theses de Pa-
ris,  1809.
  Phillips, (Sir R.)   Communications relative to
the  Datura  stramonium  in Asthma.  London,
1811,inl2mo.  (Published anon.)
  Lullier-Winslow. Art Asthme, in Diet, de*
Sc.  Med.  Paris, 1812.
  Rostan.  Mimoire sur cette question.- Vasthme
des viedlards est-il une affection nerveuse; in Nou-
veau Journ. de Med., &c.  Sept. 1818.   Paris.
  Ducamp, (Th.) Peut-on  rapporter  les symp-
toms de Vasthme piriodique aux anivrismes au
cceur ? in Journ. Gen. de Med. LXIX. 120.—Ibid.
Reflexions sommaires sur les signes distinctifs de
quelques dyspnies, in same Journal, LXXII. 132.
Paris.
  Begin.  Reflexions physiologiques et patholo-
giques sur Vasthme, in Journ. Complem. des Sc.
Med. V. 3.  Paris,  1819.
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de Paris, 1820.
  Vie.  Essai sur Vasthme.  Theses de Paris,
1821.
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ticulierement chez les vieillards.  Theses de Pa-
ris, 1821.                       ,      ,   „
  Ferrus.  Art. Asthme, in Diet, de Med. Pa-
ris. 1821.
  Pozzo di Borgo.   Lettera  clinico-patologica
sopra un  asma felicemente lerminatp.  Ajaccio,
1823, in 8vo.
  Hoffbauer.- Ein Beilrag zur Diagnose und
JEliologie des Asthma  spasmodicum  chronicum
siccum, in Hufeland's Journal, LVIII. 90.  Ber-
lin, 1824.
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dyspnies purement  nerveuses?  Theses de Paris,
1825.
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par les auteurs, in Archives Gen. de Med. IX.
334.  Paris, 1825.
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bain de riviere, with observations by Broussais ;
in Jourrt. de la Med. Phys. XI. 32.  Paris, 1827
  Bouillaud.  Suntne asthma et angina pectoris 
518                       ASTHMA.—ASTRAGALUS.
symptomatica?  Suntne essentiala?  Theses de
Concours pour l'agregation.   Paris, 1828.
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in Asthma, &c.; in Glasgow Med. Journ.  I. 177.
(1828.)
  Siry.  Quelques considirations sur VAsthme.
Theses de Paris, 1828.
  Hauffbauer.   Uber  d. Erkenntniss un cur
des Brustkrampfs Erwachsener.  Leipzic, 1828.
  Jolly.   Art. Asthme, in  Diet de Med. et de
Chirurg. Prat.  Paris, 1829.
  Kreyssig. Art Asthma,  in Encyclop. Wor-
terb. der Med. Wissensch.  Berlin, 1829.
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reported in London Med. Gaz. IX. 4%. (1832.)
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Med.  London, 1832.
  Hope, (J.)   Treatise  on  the Diseases  of the
Heart, &c.  London, 1832, in 8vo. p. 345.
  Ferrus.  Art. Asthme, in Diet, de Med. 2d
ed. Paris, 1833.
  Copland.  Art Asthma, in Diet. Pract. Med.
London, 1833.
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ment of Asthma, in  Baltimore Med. and Surg.
Journ. I. 299.  (1833.)
  Ross.   Case in which urgent symptoms of
Asthma appeared to  be induced by electricity, ex-
cited by new feathers; in Edinburgh Med. and
Surg. Joum., July, 1834; and American  Journ.
Med. Sc, May, 1835. p. 214.
  Davies, (Th.)  Lectures on the Diseases of the
Chest, &.C., reported  in London  Med. Gaz.  XV.
449.  Jan.  3,1835.
  Lefevre, (Amedee.) Recherches midicales sur
la nature et le traitement de la maladie connue
sous le nam dAsthme,  in Journal Hebdom. des
Progres des Sc. et Inst Med.  Juillet et Aofit,
1835.  Paris.
  See the Bibliography of the next article, and
of the articles Dyspnoea, Bronchitis, emphysema
of the Lungs, diseases of the Heart; also the
general Treatises  on Diseases, and particularly
the works of Kreyssig, Jos. Frank {Prax. Med.
Pracept.), Naumann (Handb. der Med. Klinik),
and Laennec {Traiti d'aucult.).
                                 I. H.

   ASTHMA of  Millar,   or   ACUTE
ASTHMA.  Millar gave the name of
acute  asthma, to a  form of intermittent
dyspncea, considered by him as peculiar
to children and common in them until the
age of puberty.   He describes it  as at-
tacking  suddenly, often at night,  like
croup, and as particularly  distinguished
by paroxysms of suffocation, accompanied
by a  kind of croaking analogous to that
observed in some hysterical attacks. These
characters, considered by Millar as diag-
nostic, also belong to croup and to several
phlegmasia?  of  the  larynx  and  trachea;
and the  uncertainty in which this imper-
fect description leaves us as  to the disease
intended to be designated, is not relieved
by the cases given in illustration, of which
there are three, so incomplete are the de-
tails.  This want of precision in the  work
of Millar has given rise to much discus-
sion among subsequent writers, respect-
ing the affection he had in view, and ren-
ders it  impossible to solve with certainty
the question.
  Underwood, Cullen,  and the Albers
(uncle and nephew), considered the acute
asthma of Millar to be croup, an opinion
in which Rush at first participated, though
he subsequently abandoned it Jurine re-
garded  it as suffocating catarrh; Joy (Cy-
clop, of Pract. Med.) as spasm of the glot-
tis ; Jolly (Diet, de Med. et de Chirurg.
Prat. III. 611.) as  nervous or convulsive
asthma, and Gdersent# seems now also so
to regard it (Diet, de Med. 2d ed.), though
formerly  he  confounded  it  with  false
croup.
  It is  an unquestionable  fact that true
nervous asthma is met with in children,
and presenting precisely the same charac-
ters as in adults and old persons;  and it
seems not improbable that this is the dis-
ease intended to be described by Millar,
though, as has already been remarked,
there are no means of determining this
with absolute certainty.

  Bibliography.—Millar, (J.) Observations on
the  Asthma and  on Hooping-Cough.  London,
1769.  8vo.
  Rush, (Benj.)  On the spasmodic Asthma of
children.  London, 1770.
  Cookson.  Diss, de asthmate infantum suffo-
cativa.   Edinburgh, 1780.
  Wichmann.  Ideen zur Diagnostick. U. 89.
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acuta infantum Millari. Wirtemberg, 1798.
  Fleisch. Diss, de asthmate Mutari.  Mar-
burgh, 1799-
  Hecker.  Von den Entziindungen in Halse,
besonders dem Asthma Millari.  Berlin, 1808.
  Loebenstein-Loebel.   Uber d. Erkenntniss
und Heilung der hautige Brdune, des  Millar-
ischen Asthma  und des Keuchusten.   Leipsic,
1811.
  Hentzschel.  Diss, de asthmatis Millari et
angina polyposa; differentia. Breslau, 1813.
  Dobrolowski.   Diss, de  asthmate  Millari.
Vienna,  1816.
  Albers, (J. C.)   Commentarius de  diagnosi
asthmatis Millari strictius definienda. Gottingen,
1817.
  Suchet, (L.)  Essai sur la pneumolaryngalgia
ou asthme aigu de Millar.  Paris,  1828.
  Guersent.  Art Asthme aigu, in  Diet,  de
Med. Paris, 1821— Ibid, in 2d edit Paris, 1833.
                                 I. H.

  ASTOMIA.  (From a priv. and atopa, a
mouth.)  Without  a  mouth.  (See Ace-
phalus.)                         I- H.
  ASTRAGALUS.  A very irregular-
shaped  bone,  situated  at the upper and
middle  part of the tarsus,  where it is ar-
ticulated  with  the tibia.   (See Foot, and
Bones.)                         I. H.
  ASTRAGALUS. (Mat. Med. and Bot.)
  Sex.  Syst.  Diadelphia decandria. Nat.
Ord. Leguminoseae.
  Gen.Ch.  Cat. five-toothed.  Carol with 
ASTRAGALUS.—ASTRINGENTS.
the keel obtuse. Legume two or half two-
celled, lower suture inflexed.  Beck.
  Thls  e*tensive  £enus'  consisting  of
nearly 250 species, most of which are pe-
culiar to Asia, is composed of suffruticose
or herbaceous plants having pinnate leaves,
furnished with stipules either distinct from
or connected with the petiole, and, in one
subdivision, the Tragacanthi with  these
petioles rigidly persistent, forming spines.
The flowers are glomerate or spiked, and
axillary or terminal.
   Most  of the spinous species  furnish a
peculiar exudation known under the name
of Gum tragacanth:  this is  more  espe-
cially the  case with those found in warm
climates, and  it is  highly  probable that
under the  same circumstances the whole
of them would afford similar  products.
This supposition is strengthened by a num-
ber of analogous instances in the vegetable
kingdom,—thus, the Liquidambar styra-
ciflua exudes large quantities of an odor-
ous balsam, in Georgia and other southern
states, whilst in New Jersey and Penn-
sylvania, it affords but a trifling quantity
of this secretion; the  same  also  is the
case  with  the  Fraxinus, which in Sicily
and Calabria produces manna, but in the
more  northern parts of Europe is almost
destitute of saccharine juice.
   All these  species of Astragali possess
the same general appearance  and charac-
teristics, and form so natural a group that
it is somewhat remarkable, that the pro-
posal of Miller to form them into a sepa-
rate  genus under the name  of Traga-
cantha  has  not been generally  adopted
by botanists.   They are, without excep-
tion, small shrubs,  with very  numerous
branches, covered with imbricated scales
and beset with long spines, these latter,
as above mentioned, being the remains of
the persistent petioles.   So great is their
analogy and resemblance to each other,
that Linn.eus  considered them all as va-
rieties of one  species, to which he gave
the name  of A. tragacantha.   The more
recent researches of Pallas, De Can-
dolle,  and  Liedebour, however, have
shown the error of this amalgamation,
though  it  must be confessed that the dif-
ferential characters they have assigned as
a guide in the  discrimination of these spe-
cies, are exceedingly vague and indeter-
minate ; many of them evidently arising
rather from the effects of climate and situ-
ation than from any inherent difference in
the plants.  In fact,  the confusion that
exists in their synonomy  is so great that
it has become  almost  impossible to ascer-
tain  what species really exist  in nature
                                   519

and what are founded on mere varieties
or the misconceptions of the describers.
   Thus,  the original A. tragacantha of
Linn^ius is the A. massiliensis Lamarck,
and the  A.  massiliensis of the former is
the A. aristatus Villars, though perhaps
not of Sieber or Sibthorp.  The A. tra-
gacantha Hablizt  is the  A. poterium
Pallas,  the  A. creticus Lamarck is the
A. echinoides Willdenow,  and  the  A.
gummifer Labillardiere is the  A. cau-
casicus De Candolle, &c.  Hence, it be-
comes extremely difficult to decide which
plants furnish the gum tragacanth  of com-
merce, though it has been clearly shown,
that this  article is only procured from the
spinous species.  The London and United
States Pharmacopoeias have in this  re-
spect   followed Olivier  (Voyage dans
VEmpire Ottoman) in ascribing it to the
A. verus.  On the other hand, Labillar-
diere states that it is procured from the
A. gummifer,  and  Sieber  from  the A.
aristatus, &c.  (See Tragacanth.)
   Some  of  the species belonging to the
other subdivisions of this genus have also
been  employed for medical purposes, par-
ticularly the  A. excapus,  a native of
mountainous regions  in Europe; the root
of this plant was highly spoken of many
years since, in secondary syphilis, as well
as in  rheumatism and gout, but more re-
cent  experience  has  shown that  its effi-
cacy  in these complaints  is very doubtful.
                      R, E  Griffith
   ASTRINGENTS.  (From astringere, to
bind.) This term is applied to a class of
medicines distinguished by  the property
of exciting  contraction in  the living tis-
sues.   That such a property is possessed
by certain  substances is  obvious  to  the
senses.  When one of these substances is
placed in contact with the skin,  an ob-
servable  shrinking of the part occurs, with
a  diminution of colour consequent upon
the contraction of the capillaries. If taken
into the  mouth, it produces in the tongue,
cheeks,  and fauces, a sense  of puckering
or constriction, which is quite peculiar,
and has been admitted among the  simple
sensations by the name of the astringent
taste. Nor  is the operation of astringents
confined to parts with which they may be
brought  into  visible  contact.   A similar
contracting power  is exercised by them,
when swallowed, upon the alimentary mu-
cous  membrane, as is evinced by the feel-
ing of tightness or constriction in the epi-
gastrium, which is sometimes even pain-
ful, and by the disposition to costiveness,
resulting probably from the closure of the
exhalent and  secretory  orifices  of the 
520                             ASTRINGENTS.
blood-vessels.  Their influence, indeed, is
felt, to a certain  extent, over the whole
system.  In the healthy state, this gene-
ral influence  is  not manifested  by any
striking phenomena; but in certain cases
of disease, as in those  accompanied with
morbidly increased discharges, it becomes
very evident in the curative effects which
result from it.
   By  some writers,  the operation of as-
tringent medicines  is supposed to be  ex-
erted exclusively upon the muscular fibre.
But there appears  to be  no sufficient
ground for this limitation  of their  influ-
ence.   It is  now  generally admitted that
every vital portion of the animal system
is endowed with the property of contrac-
tility,  which  requires only  an appropriate
stimulus to bring it into action. There is
consequently nothing in  the constitution
of our frame which would necessarily re-
strict the astringent operation to the mus-
cular fibre; and the notion is certainly not
supported  by  observation;  for, so far as
our senses can discover, the contraction
produced by the  medicines under consi-
deration, extends  equally to all parts of
every vital tissue with which they  are
brought into contact.
   The circumstance  that  dead animal
structure becomes firmer and denser un-
der the action of certain astringents, for-
merly led to the opinion, that their effects
on the living tissues might  be of the same
nature, and consequently ascribable to a
chemical or mechanical  agency.  But it
is now well understood, that the influence
of these  astringents upon dead animal
matter is owing to a combination between
the tannin of the former and one or more
of the proximate  constituents of the  lat-
ter; and it is also well  understood, that
such  a combination could  not take place
in the living body without producing fatal
disorganization. We must,  therefore, seek
some  other explanation of their operation;
and none  appears more satisfactory than
that already referred to—that astringents
offer the stimulus necessary to call into ener-
getic action the organic contractility which
essentially belongs to every vital  tissue.
   In what way astringents produce their
peculiar effects upon the system at large,
whether by the propagation of a sympa-
thetic impression from the stomach over
the whole frame, or by entering  into the
circulation and through the medium of
the blood coming into absolute contact
with every part to which this fluid is car-
ried, is a question which has not yet been
determinately  settled.   Cullen  supports
the former opinion  by  the  arguments,
first,  that  astringents  taken into the sto-
mach operate  upon other  parts of tlie
body so speedily as to render it improbable
that they have passed out of this viscus,
and secondly, that  if conveyed at all into
the circulation, they are so in quantities
so small as, when mingled with the mass
of blood, to be incapable of producing any
effect upon the  parts  with which they
may come in  contact.  But neither of
these arguments  is conclusive.  Since the
time of Cullen,  it has been abundantly
proved by experiment, that medicines are
absorbed, enter the circulation, and pass
out by the  secretions,  in the course of a
few minutes;  and  there is reason to be-
lieve that  substances,  mingled with the
blood,  produce powerful  impressions in
quantities, which, if confined in their ap-
plication to a surface communicating ex-
ternally, would give rise to no  sensible
effect. It is reasonable to suppose, that if
astringents operated upon  the  system by
means of  sympathy alone,  their effects
would be most strikingly evinced in those
organs with which the sympathetic con-
nexion of  the  stomach is  most intimate.
But this does  not  appear to be the  case;
and, as some of  the substances belonging
to  the class have been detected in the
blood or secretions  after  having  been
swallowed, it is a fair inference that they
may act remedially through the medium
of the circulation.  It is not  impossible,
however, that they combine both modes
of  operating.  In  whatever  mode their
general operation is effected,  it is  much
less observable  than  that which results
from their local application; and some
physicians have  even doubted  whether
their influence really extends beyond the
surface which first receives  their impres-
sion.  But when we consider  the results
which frequently follow their administra-
tion in diseases  of parts which they can
affect only through the  system—results
too frequent and uniform to proceed from
accidental causes—there  seems  to  be no
room  for  hesitation  in  admitting their
claim  to the rank of general remedies;
and the great majority of physicians at
present  not only believe  in the extension
of  their astringent operation to various
parts of the body,  but habitually act upon
that impression.
   The  astringent  action  is entirely dis-
tinct from that  produced  by any other
class of  remedies.  It has been thought to
bear some analogy to that of tonics;  and
there is  one condition of system in which
its effects may be considered as identical,
to  a certain extent, with  those  produced 
ASTRINGENTS.
521
by the medicines alluded to.  Thus, when
debility  is connected with a relaxed con-
dition of the tissues, astringents,  by re-
storing  their natural tension or solidity,
act the part of tonics, and give increased
vigour to the organ affected or to the sys-
tem at large.   But still, the tonic action,
properly speaking, is essentially different
from the astringent  By the former, all
the natural powers of the system,  or any
of its parts to which the medicine may be
directed, are invigorated; the healthy ac-
tions are exalted in degree without being
changed in nature; and the results, when
the application of the remedy is properly
directed and kept within due bounds,  are
simply  those of  increased  health  and
strength.   By the latter,  only one  of the
vital  properties is essentially called into
action—namely, that of organic contrac-
tility—and the  effect is often to restrain
or derange some of the  healthy functions,
as, for example, that of secretion.   It is
true,  that the  tonic power is very often
associated with the astringent in the same
medicine, either in consequence  of  the
union ofa bitter with the astringent prin-
ciple, as in many vegetable products, or
of such an internal constitution in the re-
medy as allows it to combine two distinct
physiological properties in the  same par-
ticles, as in several metallic preparations.
But  that  they are  not essentially asso-
ciated is  proved by the  fact, that some
medicines   are  powerfully   astringent,
which,  so  far  from being tonic, are di-
rectly sedative in their influence upon the
nervous, and in some  measure probably
also upon the circulatory,  system.   Such
are the preparations of lead.  These ob-
servations  are  not without an important
practical bearing.   As  astringency is as-
sociated, in different medicines, with other
properties which are of a diversified  and
even  opposite  nature,  it  is  necessary, in
the employment of these medicines, to ex-
tend our views beyond the property which
characterizes them as a class, and to take
care that there exist  no incompatibility
between them and  the existing state of
the system.  Thus, it would be improper
to employ a tonic astringent under  cir-
cumstances which might justify or even
demand the use of one of a sedative char-
acter. We may often advantageously give
the acetate of lead in the early stage of
hemorrhages, when  the vegetable  astrin-
gents might be deemed  improper from the
possession of a tonic or stimulant power.
  Therapeutical application.  The medi-
cines  belonging to this  class are  ca-
pable  of fulfilling  three  distinct uidica-
                  44*
tions in the treatment of disease.   They
correct  a  morbid laxity of the tissues,
by  their  general astringent  influence;
they suppress or restrain unhealthy dis-
charges,  by closing  the  vascular orifices
through which the eliminated fluid passes;
and they obviate  inflammation  in certain
stages, and in certain positions, by dimin-
ishing  the capacity  of the  blood-vessels,
and thus  lessening the quantity of blood
in the  part affected.   A few general ob-
servations  under these three heads will
embrace  all  that it  will be necessary to
say at present in relation to the therapeu-
tical employment of astringents.    More
precise rules for their practical applica-
tion will be given in treating of the par-
ticular remedies which compose the class.
  1. A general looseness of texture in the
solids,  marked by a softness or flabbiness
to the touch, paleness, deficient muscular
and vascular energy,  and an almost uni-
versal  feebleness in  the performance of
the vital functions, occurs as an accompa-
niment or consequence of various chronic
complaints, particularly those of a scrofu-
lous nature, which it tends to  aggravate,
and to render more obstinate.  Here, as-
tringent  medicines united with tonics, or
such as  combine in  themselves both as-
tringent   and  tonic  properties, will be
found highly useful.   They may be taken
internally, and  at the same time,  espe-
cially in infantile cases, applied externally
in the form of baths.
  Diseases consisting in local relaxation
call for the  use of astringents upon the
same principles; but in these it is  requi-
site that the remedy  should be applied as
nearly as possible to  the part affected. In-
stances of this kind we have in prolapsus
of the uvula, anus,  and uterus, not con-
nected with  inflammation of these parts,
and in some forms of varicose  veins.
  2. The  obvious applicability of astrin-
gents  to  the suppression of morbid dis-
charges, has rendered their use in these
affections almost universal.   It is of little
consequence whether the discharge con-
sist of blood unaltered, or some increased
secretion.  In either case, the fluid es-
capes,  as a general  rule, through natural
outlets, which,  in the instance  of the he-
morrhages at least,  must  be  much en-
larged ; and astringents,  by narrowing or
closing these outlets, afford apparently
the readiest means of cure.  But they can-
not be used indiscriminately in all condi-
tions and  stages of these affections.  It
often happens that the discharge is conse-
quent upon some irritation, congestion, or
inflammation, perhaps of a dangerous char- 
522
ASTRINGENTS.
acter, existing  in the  part from which it
proceeds, or in  some other portion of the
system.  This  morbid  condition it may be
calculated  to relieve, and its untimely
suppression may therefore lead to unplea-
sant consequences.  This is  particularly
the case in the earlier stages of the dis-
ease.   Under such circumstances, the use
of astringents  would  either be attended
with  no effect in  controlling  the dis-
charge, or would  do injury  by arresting
it.  The better plan is to address our re-
medies to the root of the disorder, and to
endeavour to check the evacuation by re-
moving its cause.   Most of the astrin-
gents, moreover,  possess  excitant proper-
ties, which render them  peculiarly inap-
plicable to the  earlier  stages of inflamma-
tory  affections.  Occasionally, however,
the evacuation, even when dependent on
a local disease  which  it may be intended
to relieve, is so profuse as to endanger se-
rious if not fatal  exhaustion,  and there-
fore to constitute the chief point for the
physician's attention.   In this case,  the
use of astringents may be resorted to even
at the risk of local injury. Again, it very
frequently happens, that the evacuation
continues  after the irritation  in which it
originated has ceased, being kept  up by
the new habit which the vessels have ac-
quired, or  by a state of relaxation follow-
ing the previous excitement.   Here also,
astringents are indicated, and often prove
highly useful.  Lastly, the discharge some-
times originates in a debilitated or relaxed
 condition  of the vessels, which  disables
 them from affording the  due  resistance  to
 the circulating power; and  the blood,  or
 some one of its constituents  but slightly
 modified,  passes out  almost mechanically
 through the open orifices. In these cases,
 astringents are the most effectual reme-
 dies, and may always be safely employed.
   The  operation  of  these  medicines  is
 most effectual when  they can be applied
 directly to  the part  from which the dis-
 charge  proceeds.  Hence, their  external
 use is generally followed by more striking
 results than their internal.   Hemorrhage
 from the nostrils and rectum, excessive
 perspiration, and unhealthy secretions from
 the urethra, vagina, &c., are often imme-
 diately  or very speedily arrested by  the
  judicious employment of astringents  di-
  rected immediately to the part affected.
  Of the diseases treated by their internal
  use,  those which  have  their seat  in  the
  stomach  and  bowels are most sensibly
  benefited, for the very obvious reason,
  that the  medicine is brought into imme-
  diate contact with the  diseased surface,
and thus superadds a direct impression to
that which is felt by the alimentary canal,
in common with all other parts of the
body, from its general action upon the sys-
tem.   Hence the great importance of as-
tringents in the treatment of those forms
and states of diarrhoea which come within
the rules already given for the  employ-
ment of these  medicines in the suppres-
sion of morbid discharges.  In hasmateme-
sis and hemorrhage from the bowels they
also prove  highly beneficial; and they
may sometimes be usefully employed in
that relaxed condition of the bowels which
occasionally supervenes  upon an attack
of dysentery, or attends that complaint in
its chronic forms.  But though most ob-
viously useful  in external complaints, or
those seated in the alimentary canal, they
may often be used with great advantage
in the hemorrhages and profluvia of other
parts.   Thus,  astringents are habitually
employed in haemoptysis, menorrhagia or
uterine  hemorrhage, hasmaturia,  profuse
sweating, diabetes, and  excessive secre-
tion from the  mucous membranes, parti-
cularly that of the bladder.  It should al-
ways, however, be borne in mind that in
these affections such measures as are cal-
culated  to  relieve any existing local in-
flammation or  general   plethora,  should
precede the use of astringents, which, by
their proper action, can answer no other
purpose  than  merely to check  the di%
charge.
   3. It has been  stated  that  these medi-
 cines  sometimes prove useful in local in-
 flammations,  by diminishing the calibre
of the capillaries, and thus partially ex-
 pelling the blood from the seat of the dis-
 ease.  But it is clear  that they can be use-
 ful in this way only when applied directly
 to the  inflamed part.   The  contraction
 which results from their general influence
 upon  the system is  universal, and cannot
 therefore diminish the relative amount of
 blood in any one spot   Even in  inflam-
 matory  affections to which they can be
 directly  applied, they will  not  be found
 useful in all stages, and in all forms of ap-
 plication.  On the contrary, when the dis-
 ease is confirmed, or of an aggravated na-
 ture, so far from relieving, they will often
 increase it, especially when employed in
 a concentrated state. The irritation which
 most of them  are capable  of producing,
 more than counterbalances,  under such
 circumstances,  any  good that can arise
 from their astringent action.  The con-
 ditions of  inflammation in which they are
 most useful are those which occur in its
 incipient and  declining stages—particu- 
ASTRINGENTS.—ATAXIA.
523
 larly the latter, when the calibre of the
 capillaries often remains  unduly enlarged
 from the loss or  diminution  of their con-
 tractile power, and the signs of inflamma-
 tion linger from this cause.  The cases in
 which they are employed are those of in-
 flammation of the conjunctiva, of the mu-
 cous membrane  lining the mouth, throat,
 nostrils, urethra, vagina, and rectum,  and
 of the skin.   The mineral astringents are
 usually  preferred,  and of these the pre-
 parations of lead are,  perhaps,  the most
 efficient; as they  combine  a degree of
 sedative power with their astringency.
    Division of Astringents.  This class of
 medicines may very properly be arranged
 in two  subdivisions—one including those
 of vegetable origin,  the other  those de-
 rived from the mineral kingdom.
    The vegetable astringents are charac-
 terized by the presence, among their con-
 stituents, of a peculiar proximate princi-
 ple,  or  perhaps  set  of principles,  called
 tannin,  in which their astringency chiefly
 resides.  Tannin differs somewhat in che-
 mical properties as found in different ve-
 getables, but  its effects  upon the system
 are essentially the same  in all its varie-
 ties.  The  medicines belonging to  this
 subdivision  may, therefore, be considered
 identical so far  as regards  the  character
 of their astringent action.   They differ
 from each other  only in the  properties de-
 rived from the other principles with which
' the tannin is associated.   These are  usu-
 ally bitter or aromatic, and have the effect
 of rendering  the  astringent more tonic
 and  stimulant than  it would be without
 such combination.   The chief difference,
 therefore, between the several vegetable
 astringents  is in the degree of their tonic
 and excitant power, and  reference  should
 be had to this point in their application to
 the treatment of disease. The purest are
 the least stimulating,  and  should be pre-
 ferred when the object is merely to obtain
 the astringent effect.   But those in which
 the  tannin  is least mingled with other
 principles,  are  still somewhat  excitant,
 and should not as a general rule, be em-
 ployed  in  states of considerable  excite-
 ment.   Gallic acid is also usually men-
 tioned  as an astringent principle.   It is
 very often  associated  with tannin in ve-
 getables, and, in addition to its sourness,
 Has a slightly styptic taste; but the  pro-
 bability is  that  it  scarcely modifies the
 properties of the particular substances  in
 which  it is found,  and its presence or ab-
 sence may  be considered as an object of
 indifference  in  the choice  of one of the
 vegetable  astringents.   The individuals
belonging to this division of the class are
very numerous; but as many of them are
nearly identical in  properties,  compara-
tively few are at present employed. Those
most in use in this country are,  oak bark,
galls,  kino,  catechu,  rhatany,  logwood,
and the  roots of the Rubus  villosus  and
trivialis,  and  of the Geranium maculatum.
Bistort, tormentil, red roses, and the rind
of the pomegranate, are considerably used
in Europe.  A vast number of  vegetable
products unite astringency with other pro-
perties which it tends somewhat to  mo-
dify, though  it is not that for which they
are chiefly used. Such are, uva ursi, pip-
sissewa,  tea,  coffee, rhubarb, sage, cinna-
mon, and most of the tonic barks, besides
many other substances which it would be
useless to enumerate.
  The mineral astringents have nothing
in common but their astringency.  Each
of them  is characterized by properties pe-
culiar to itself, and is consequently sus-
ceptible  of a peculiar practical applica-
tion.   Thus, in addition to the properties
which characterize  them  as  a  class, the
salts of iron  are tonic and  emmenagogue,
those  of lead  are sedative, sulphate of
zinc is tonic  in small doses and  emetic in
larger, sulphate of copper is tonic in small
doses, emetic in large, and escharotic in
its local  action; and thus  throughout the
whole catalogue.  It is obvious,  therefore,
that no  other remarks are applicable to
this division  of astringents, either in rela-
tion to  their properties or employment,
than such as have already been made un-
der the  general head.  The practitioner,
in selecting any one of them to meet the
indications for the use of astringent reme-
dies,  will be  governed by  the peculiar
adaptation of its properties to the existing
state of the system, or to some peculiarity
in the disease.  The most prominent min-
eral astringents are the acetates of lead,
the sulphate and acetate of zinc, the sul-
phate of copper, the soluble salts of iron,
alum, sulphuric acid,  and lime and its
carbonate.             Geo. B. Wood.
   ATAXIA. (From a priv. and ra|tj, or-
der.)  Disorder, irregularity,  malignity.
This  term,  if employed  in  accordance
with its etymology, would signify every
disorder, every morbid condition; for when
an organ is diseased, its actions and func-
tions  become disordered,  irregular,  and
perverted ; and it is in this extensive sig-
nification  that it was  used by Hippocra-
tes.   Subsequent writers  have, however,
employed  it in a more restricted  sense.
Galen applied it more especially to irre-
gularity of the pulse; Sydenham to dis- 
524                      ATAXIC—ATMOSPHERE.
order of the  nerves.  Ataxia spirituum,
irregularity of the animal spirits,  is, ac-
cording to this last author, the source  of
hysteria and hypochondriasis.  By modern
writers,  it is employed to  designate a
group of phenomena remarkable for the
gravity of the  organic affections  with
which they are connected and for the ir-
regularity of the course of these diseases.
These  phenomena  consist in  weakness,
perversion, or abolition of the functions of
the organs of the senses; complete and sud-
den alteration of the countenance; extreme
and convulsive  movements  or paralytic
immobility of the muscles of the eyes and
face; weakness of muscular power, so that
the patient is obliged to remain in bed, at
the  same time  that he is affected  with
partial  spasms,  cramps, subsultus tendi-
num, carphology, or rather great muscu-
lar agitation, a  general spasmodic state,
tetanic rigidity, epileptic paroxysms, and
sometimes instantaneous increase of mus-
cular  strength,  followed by its  sudden
loss; alteration of the voice,  aphonia;  pa-
ralysis  of the bladder, of the pharynx, of
the oesophagus, and of the sphincters of
the  rectum; obstinate insomnia or  sleep
disturbed by  frightful dreams, starting out
of  sleep, nightmare, agitation of mind;
somnolence,  stupor or  furious delirium;
epileptic, cataleptic, apoplectic, or hydro-
phobic  state, syncope, &c.  (Georget, in
Diet, de Med. 2d ed. IV. 295.) If  these
disorders be  traced to  their source, they
will be found to arise from an affection of the
central nervous mass; ataxia is therefore
dependent upon some grave  lesion of the
brain.  But  as the term has no reference
to this condition, but is attached to uncer-
tain  and irregular groups   of symptoms
many of them the result of secondary af-
fections, its  signification is  too vague to
be retained in scientific nomenclature, and
it should be  stricken out of the medical
vocabulary.  (See   Encephalitis,  Fever,
Meningitis.)                   I.  H.
   ATAXIC.  Atactus.   Appertaining to
the state of ataxia.   Selle and Penel ap-
plied this term to a class of fevers  (Fie-
vres ataxiques), which comprise the  affec-
tions known by the  epithets of malignant,
putrid, nervous, cerebral, pernicious,  ty-
 phoid, fevers. (See Fevers.)     I.  H.
   ATHEROMA.    (From  a6neo.,  pulp.)
aBr^ufta, Atheroma. An indolent encisted
tumour containing a thick whitish matter
resembling pap or  bouillie.   (See  Wen,
and Tumours.)                  I.  H.
   ATHEROMATOUS.  Of the nature
of  atheroma.                    I.  H.
  ATLAS.   The  first  vertebra  of  the
neck. (SeeVerte6r<E,and Bones.)  I. H.
  ATMIATRIA.  (From crfftoj,  vapour,
gas, and tarsia, treatment)  Treatment
of diseases by gases or vapours,  a term
recently devised by Martin Solon.
                                I.H.
  ATMOSPHERE.   Art. I.  Physical
and Chemical History.  The  mass of air
by  which the  earth  is surrounded,  and
which extends  to  a considerable  but un-
known height above its surface, is termed
the  atmosphere.   It  is the  element in
which we live, and exerts, both by its  me-
chanical and chemical properties, a most
important influence  on the animal eco-
nomy.  We  shall  consider these  proper-
ties briefly, in the  present article.
  The  atmospheric air is a permanently
elastic fluid.  In what is usually assumed
as its standard condition, (that is, when its
temperature  is 32°,  and  its  elasticity is
capable of supporting a mercurial  column
of 30 inches,) it is 770 times  lighter than
water, — a cubic  foot  of air  weighing
567.89 grains.
  The  air is  highly compressible  and
elastic, and  experiment has  proved that
its  elasticity is directly proportional to its
density: so that if, at its ordinary density,
it can support 30 in. of mercury, at double
that density it will support 60 in., at half
that density 15 in., &c. It is this property
which is called the Law of Mariotte.
   As the air has weight the atmosphere
must exert  a pressure upon  any  surface
on  which it rests.  The  amount  of this
pressure is  readily determined from the
corresponding  height of  the barometer,
and, when this height is 30 in., is equal to
nearly 15 lbs. on every square inch, or to
almost  a ton on every square foot. Now
the surface  of the human body  is esti-
mated  at from  12 to 15 feet: we may
judge  then  of the  enormous pressure
which is constantly exerted  upon it, and
we may well inquire how it is that we
are enabled  to  bear  so great a  burden.
The paradox is, however,  easily resolved;
for it is evident that  the pressure of the
air in any one direction  must be  exactly
counterbalanced by an equal pressure in
the opposite direction.   Thus the force
acting  upon  the right  side of the body,
and which would impel it toward  the left,
is opposed and brought into equilibrium
by  an equal force acting on the  left side
of the body, and which would impel it to-
ward the right.  As to the tendency which
the pressure  of the atmosphere exerts to
crush the body  together, this  is prevented 
ATMOSPHERE. (Phys. and Chem. Charac.)
525
by the elasticity of the solids, liquids, and
gases, that enter into its composition, and
which need only be equal  to that of the
surrounding air, in order that the pressure
of this fluid may be wholly insensible to us.
  The weight of the atmosphere, as indi-
cated by the barometer, is, even in the
same situation, continually varying, though
generally within narrow limits.  At the
level of the ocean, the  mean  height of
the barometer  is very nearly 30 in.; but
it oscillates, in  different conditions of the
atmosphere, from 28 in. to  31,—the  pres-
sure  upon the human body varying,  of
course, in the same proportion.
   The  compression  of the air,  in  any
place, is entirely due to the weight of the
column  of air which rests upon it.   It fol-
lows, therefore,  that this compression
must become less as we ascend in the at-
mosphere, the superincumbent column be-
coming not  only shorter, but also of less
mean density.   In fact, mathematical cal-
culation, fully  confirmed by experiment,
proves that as  the distance  above the sur-
face of the earth increases  in arithmetical
progression, the density of  the air dimin-
ishes in geometrical progression.   Hence
we find that in very elevated positions the
air has  a great degree of tenuity.   Thus
at the monastery of the benevolent monks
of Mount St. Bernard, 11,000 feet  above
the level of the sea, the air has its density
reduced to  less than  two-thirds of that
which it has  at this  latter level; and at
the highest summit of the Himalaya moun-
tains, which is at the prodigious elevation
of 26,260 feet or more  than five  miles,
the density of the air  is nearly reduced to
one-third.
   The enterprise of man has carried him
to these vast heights, and it has been con-
sidered very remarkable that he should be
able to  bear, without  sensible inconveni-
ence, so great a change in  the medium by
which he is surrounded.   It must be re-
marked, however, that  to accommodate
their elasticity to this new pressure, the
solids and liquids of the  body need un-
dergo only a very minute change  in vo-
lume.  Thus when the pressure of the air
is entirely removed from water, as in the
well-known experiment of Canton,  it ex-
pands only one part in 21,740 ;  and it is
probable that  the solid and liquid consti-
tuents of the body would not experience
a more  considerable  change under the
same circumstances.   As to the gases m
the system, they  are  either  in  cavities
which communicate freely with the sur-
rounding-  air,  or they exist m too small
quantity to give rise to any inconvenience
by their expansion.   It  is true that all
travellers who have ventured into these
elevated regions  agree  in stating that
they were  exhausted by the smallest ex-
ertion, and had to stop every few steps to
pant and to recruit their strength.   This,
however, was no doubt principally owing,
not to the change of pressure, but  to the
diminished quantity of air supplied to the
lungs in respiration.  The uneasiness may
also  in part arise from the extreme dry-
ness of the air at great  heights.  It was
of this, principally, that Gay-Lussac, who
was  not subjected to any  personal exer-
tion,  complained,  during his celebrated
aerial voyage, in  which he  rose  to the
height of 23,000 feet,  and had  the mer-
cury in his barometer standing  below 13
inches.
  The atmosphere is subject to  great va-
riations of temperature,  constituting the
diversities  of climate  and season.  The
source of the atmospheric  temperature is
the sun; though its direct rays have but
little influence upon the  air, which trans-
mits them nearly  all freely to the earth.
Here, however, they are arrested, and the
ground becoming heated  communicates
heat to the air in immediate contact with
it which is thus expanded,  rises  in the at-
mosphere by its superior  levity, and is re-
placed by colder and heavier air.  This,
in its turn, is heated by contact with the
ground, expands,  rises,  and is  replaced.
Thus a kind of circulation of the air is
established, and by  this  indirect process
the  atmosphere derives  its  temperature
from the sun.  It is probable also that the
air arrests a  large part of the dark calo-
rific rays which emanate from the heated
ground; since it  is  an  established  fact
that transparent bodies are  much less per-
meable to these rays than  to those which
accompany the light.
  As the heated air rises,  it  is  subjected
to less pressure,  and consequently ex-
pands ; and, if it retained its excess of tem-
perature, it would always  continue to be
lighter than the surrounding air, and to
rise; and  thus the  heat of the  ground
would be conveyed to the highest regions
of the atmosphere.  But it is proved by
experiment, that as  the density  of air di-
minishes, its  capacity for heat increases,
or it requires a greater amount of caloric
to heat it to the same degree.  It follows,
therefore, that from this cause, as well as
from radiation, the air, as it  rises, must
have its temperature reduced, so that the
higher  regions of the atmosphere must
always  be  colder than the lower.   This
reasoning is fully confirmed by observa- 
526             ATMOSPHERE. (Phys.

tion.  Hail  is formed in the high* clouds,
in midsummer ; very elevated mountains
are covered with perpetual snow, even in
the torrid zone ; and the  aeronaut when
he rises to a great height, always suffers
from  the  cold, whatever be the season of
the year.
  The air is almost always in motion, thus
forming more or less rapid winds.  These
are in general dependent, in the first in-
stance, on variations of temperature ; but
many of the phenomena are also to be re-
ferred to  the unequal absolute velocities
with  which portions of the earth in differ-
ent parallels of latitude move, in conse-
quence  of the earth's  rotation about its
axis.  The  further discussion of this in-
teresting  subject must, however, be intro-
duced under another article.
  The atmospheric air is composed of two
simple  gases, oxygen  and nitrogen, of
which the  former  seems to be the true
supporter of life in respiration.  Chemists
are not wholly agreed as to the exact  pro-
portion  in which these gases enter  into
the composition of the air, though  the
general estimate is, that there are, in 100
parte by  volume of atmospheric air, 21
parts of oxygen and 79 of nitrogen.  Other
chemists, however,  among whom  are
Thomson, who seems  to  have  employed
in his experiments every means to insure
accuracy,  make  the  proportion  of  the
gases 20 and 80, or as 1 to 4 exactly.
  It  has  been a subject of much discus-
sion,  whether the  constituents of the air
were simply  mixed  together,  or were
united by a real though feeble chemical
combination.  The decision of this ques-
tion must in  part depend upon the true
proportions  in which the  oxygen and ni-
trogen are  found in the  air; for  it  is a
well-established  law,   that  when  gases
combine chemically, they always do so in
exact and simple  proportions of volume.
Thus, with  regard  to the  two gases now
under our consideration, 2 volumes of ni-
trogen united to 5 of oxygen form nitric
acid,  2 nit. and 3 ox. form nitrous  acid, 1
nit. and 1 ox. form nitric oxide, 2 nit  and
1 ox.  form nitrous oxide.  Now if Thom-
son's analysis be correct,  atmospheric air
would take  its place, in the same series,
as a  compound of 4 volumes of nitrogen
and 1 of oxygen.
  A remarkable circumstance respecting
the composition of the air, and one which
greatly favours the  opinion  of its being a
chemical compound, is  the  fact that  the
proportions  of oxygen  and  nitrogen  are
always found to be exactly the same, in
whatever  part of the globe the air may be
and Chem. Characters.)

taken, and whether it be collected from
the surface,  from the deepest  mines, or
from the greatest elevation to which the
balloon has ever reached.
  Besides these constituents of the atmo-
spheric air, other substances are met with,
which, however, enter in small and vari-
able quantities, and cannot therefore be
considered as essential ingredients.  One
of these is carbonic  acid gas, which is
found in the proportion of one hundredth,
one  thousandth part, and even less, the
quantity being  dependent upon  the situa-
tion, the season, and other circumstances.
This gas is one of the products of respira-
tion,  combustion, and fermentation, and
from these ample though variable sources,
the air receives, no doubt, in part at least,
its supply.
  Hydrogen, in the proportion of one part
in 10,000, has been found by M. Boussin-
gault, in the  air of Paris; and sulphur-
ous acid gas is met with in the air of Lon-
don.  A flocculent organic matter is also
said to be found  in the air  over marshy
grounds.  But  these  are unquestionably
accidental admixtures.
  Another substance which is always pre-
sent  in the atmosphere, and which acts
there a most important part in tlie econo-
my of nature, is the vapour of water.  It
was at one time supposed that the vapour
was dissolved  by the air, and held sus-
pended in it as salt is in water.  It is now
known,  however, that this notion is incor-
rect, that the air is passive with regard to
the vapour, and that, at the  same  tempe-
rature,  the  same quantity of vapour ex-
actly will be formed and suspended, over
water, in the same space, whether it be a
vacuum, or filled with air. The maximum
of vapour in the air depends, in fact, upon
its temperature alone.  Thus, at 32° F.,
it may amount to 2.555 grains in a cubic
foot at  52° to 4.861 grs., at 72° to 8.977
grs.,  at 92°  to  15.880 grs.   In general,
however, the amount falls  short of this
maximum, and the hygrometric condition
of the air is indicated by the ratio between
the quantity of vapour actually in the air,
and the maximum quantity which it could
contain at the given temperature.
  When, by any means,  such as the ab-
sence of the sun, the blowing of a cold
wind, or the rising of the vaporous air in
the atmosphere by its  superior levity, the
temperature of the air is reduced, it may
be no longer able to  contain, in the gas-
eous form, the vapour which had been be-
fore suspended in it, and then a portion of
this vapour will be reduced to the state
of a  liquid, assuming  the appearance of 
                     ATMOSPHERE.  I

fine globules floating in the atmosphere,
and to which, as they are supposed to be
hollow, the name of vesicular vapour has
been given.   When this vesicular vapour
rests  upon the  surface  of the earth,  it
forms mists  and fogs;  when it occupies
the higher regions of the air, it forms the
clouds.   Sometimes,  by  an increase  of
heat  these  liquid vapours  are dissolved,
and converted  into true  transparent gas-
eous vapour,—an occurrence witnessed in
the dissipation of fogs by the presence of
the sun.  At other  times, the accumula-
tion becomes excessive, and the vesicles
 join together in drops, which  finally fall
to the ground in the form of rain.  Fre-
quently the vapour of the clouds is frozen,
assuming the shape of feather-like crys-
tals, and producing snow.
   Though the air is eminently transpa-
 rent,  it must not be considered as com-
pletely  so.   Many of the solar rays are
arrested by the air in their course, and re-
 flected from it in all directions.  It  is, in
fact, this reflected light that renders the
 atmosphere  luminous, and which consti-
tutes what is commonly understood by the
term day-light. Were it not indeed for the
light  thus universally dispersed through-
out the air, no bodies would be visible ex-
 cept those actually placed in the sunshine.
 It  is this illuminated  atmosphere  also
 which renders objects  visible  before the
 rising and after the setting of the sun,
and which thus forms the  dawn  and the
 twilight.
   Although the air  is capable of reflect-
ing all the differently coloured rays, it is
the blue  which are reflected  with the
greatest facility, and in the greatest quan-
tity.  This is the reason why large bodies
of air always present this hue, which is
as much the proper colour of the air, as it
is of the violet and for precisely the same
cause.  Besides the colour of the sky, we
have  another evidence that blue predomi-
nates in the light reflected from the air,
presented to us in the shadows  cast upon
the snow; for the snow in these shadows
has always a decidedly bluish tint, and the
light  by which it is seen is only that
which has fallen upon it from the air.
  In this article, several subjects,—such as
climates,  seasons, winds, hygrometry,—
have been incidentally introduced, which
are of too great importance in their me-
dical  applications not to require  a sepa-
rate and much fuller discussion, for which,
therefore, we refer the  reader to the ap-
propriate titles.      R.  M. Patterson.
  Art. II. Atmosphere. (Hyg. and The-
rap.)  No subject of Hygiene is more inte-
Hyg. and Therap.)                  527

resting than the  influence of the atmo-
sphere  on  human  health, — considered
either singly, or in combination with those
local characteristics that  occasion such a
diversity in the salubrity of different coun-
tries, and of different districts of the same
country.  Whilst we observe the inhabit-
ants of the more  mountainous regions of
our own country enjoying robust health,
we may find those of the lower districts
near the ocean, or dwelling on the banks
of our larger streams, liable to diseases that
are endemic, or the products of such situa-
tions ; and daily observation instructs us,
that the air of the city is  not possessed of
all those advantages for  the preservation
of health, which the  more pure air of the
country affords.  We find,  again,  that
particular regions of the globe are liable
to diseases known  only  to them.   The
base  of lofty mountains  constitutes a lo-
cality almost  everywhere favourable  to
the development of the goitre, or " swell-
ed neck."  The  smiling plains  of Italy
are  saddened  by the prevalence of the
pellagra (q. v.), a loathsome cutaneous af-
fection ; and the plains of the torrid zone
are  infected with the yellow fever.  All
these  diseases  are  connected with local
causes,  and are  produced by particular
conditions of the atmosphere, united with
certain  emanations from the  soil, which
last  indeed,  have by some been looked
upon as the sole cause  of the difference
of salubrity between different countries.
(See Climate.)
   Where a particular affection is univer-
sally prevalent in a locality,  it must be
presumed, that the " constitutio aeris"—as
Sydenham termed  it—is always favour-
able, and  unites with other local causes
so as to maintain the necessary causation;
but where we  observe a district—previ-
ously  healthy—perhaps  even signalized
for its salubrity,  devastated by  a malig-
nant disease, a precise union of the requi-
site atmospheric and local influences must
be formed to  induce it; and  the reason
why it never again occurs in such a dis-
trict, or does so only after a lapse  of years,
is, that the necessary catenation of causes
is wanting.
   In this way, we account for the appear-
ance of yellow fever occasionally in our
seaports, and for its annual presence  in
the torrid regions of the  globe.  Unfortu-
nately, as we  shall find, it  is easier  to
suggest the influences that occasion en-
demics and epidemics (see these words),
than it is to explain the precise nature or
operation of such influences.
   On the main points of  meteorology we 
528
ATMOSPHERE.  (Pressure.)
are  signally  deficient  in  information.
There are  physical  circumstances that
determine the  shape of to-day's  clouds,
and  a knowledge of which would  have
enabled us to prognosticate their presence;
but  this  knowledge  is far beyond our
limited powers  in the present state of sci-
ence.  Still more  restricted is  our ac-
quaintance with the  meteorological con-
ditions that affect human health; nor can
we indulge the expectation, that future
improvements  in science will  enable us
to possess an accurate knowledge of the
subject.  There are many interesting to-
pics, however, connected with the matter,
which we do know, and on which we pos-
sess much information of a valuable char-
acter.
   It  has been already shown, that the air,
which everywhere surrounds the earth,
and the total mass of which constitutes
the atmosphere, is a ponderable, perfectly
elastic fluid, consisting chemically of oxy-
gen  and nitrogen;—that,  in addition to
these chief constituents, carbonic acid can
always be detected in it; and that it hold's
water in a state  of vapour; caloric; the
electric fluid; and a multitude of matters
continually emanating from the earth, or
from  its  animal or vegetable occupants.
Into   the  influence  exerted on  human
health, by its various  and varying condi-
tions, it  is our present object to inquire.
   § 1. Atmospheric Pressure. The range
of the barometer varies from about 28 to
31 inches; and if the changes are not ex-
tremely sudden between these  extremes,
the human frame is not very liable to suf-
fer ;  but  if we  descend  far below the sur-
face  of the earth,  or ascend to a great
height in the atmosphere, changes—espe-
cially if the range has been to a great ex-
tent, and suddenly experienced—may be
produced  in many of the  functions, and
more or less indisposition be excited.
   Our acquaintance  with the  effect of
great augmentation in the density of the
air is comparatively more  limited.  The
only means we possess of observing the
former is in mines  penetrating  far be-
neath the surface, and perhaps in no case
have these  exceeded a league, and that
not  in a  perpendicular direction, whilst
the phenomena,  attendant  upon a  rapid
passage  into a rarer atmosphere,  have
been observed  at nearly 23,000 feet or
upwards   of four  miles   perpendicular
height.
   Where the weight of the air is largely
increased,  as in  mines, it  is fair to pre-
sume, that the  respiration should be slow-
er, on account of the  same quantity of
oxygen being contained in a smaller bulk
of air.  It has  been presumed, also, that
the greater density of the air may con-
strain the inspiratory movements, so as to
render them less frequent; but this,  al-
though specious, is conjectural.
  It does not seem, that any augmented
pressure, hitherto experienced in. subter-
raneous excavations,  has been  attended
with danger.  Rostan, indeed, conceives
it to be favourable to health.   " To this,"
he remarks, " it may perhaps be objected,
that in mines,  the  workmen, instead  of
being  in better health, seem to be disad-
vantageously affected; but if we consider
that in such a case, the favourable action
of the pressure is more than compensated
by the mineral exhalations  prevailing in
these deep excavations, by the absence of
light, hard labour, want of ventilation, &c.,
reasons sufficient may be found to explain
why the unfortunate individuals, that are
buried alive in  these excavations, drag on
a languishing existence, and  die prema-
turely."  (Rostan,  Art. Air, in Diet de
Med., lere edition.)
  Experiments with the diving-bell would
throw some light on the effects produced
by suddenly augmented density of the air,
but here a source of fallacy exists, in the air
being  rapidly deteriorated by respiration,
—the  oxygen disappearing, and carbonic
acid,  which  is directly unfavourable to
animal life, taking its place.  From this
conversion, the  respiratory  movements
would be speedily deranged, and the ef-
fects of defective aeration of the blood be
soon apparent.
  We have more numerous opportunities
for witnessing the effect of diminution in
the density of the air.  If an animal be
placed under the receiver of an air-pump,
and the air be exhausted, the air within
the body being no longer counterbalanced
by  the pressure  of the air without  ex-
pands, the  animal  appears  inflated, and
soon dies.  In the mammalia, birds, fishes,
&c., death is occasioned from this cause,
as well as from the want of a due quan-
tity of oxygen in the rarefied medium sur-
rounding them; but the amphibious ani-
mal, which is capable  of subsisting for  a
long time without air,  appears to  be  but
little incommoded by its abstraction.
   Many fishes  are provided with an appa-
ratus, called the  swim-bladder, which re-
gulates their specific gravity according to
circumstances,  and if they  be placed un-
der the receiver of an air-pump, the air in
the bladder dilates  until it bursts, after
which they are unable to rise through the
water, but  crawl, as it were, along  the 
ATMOSPHERE.  (Pressure.)
529
 bottom.  Biot asserts, that similar results
 occur to many kinds of fish, when taken
 at great depths, or even at the depth of
 from 70 to 100 feet.  So long as they re-
 main at the depth  to which they are ac-
 customed, the air of the swim-bladder has
 the degree of compression, and elasticity,
 necessary  for supporting the column of
 water constantly pressing upon them; but
 if they be  suddenly raised to the surface,
 the bladder swells,  and  bursts, and the air
 which it contained, occupying now eighty
 or a hundred times more space,  fills the
 cavities of the  body, forces the  stomach
 out  of  the mouth,  and  kills them.
   It is only, however, when the pressure
 is suddenly removed, that these pheno-
 mena are witnessed.  When the transi-
 tion is  more tardy, the animal  possesses
 the  power of regulating the quantity of
 air contained in this receptacle, so that
 no evil can result
   Effects of a similar kind would be pro-
 duced  in  the human body by any very
 sudden abstraction  of the  ordinary atmo-
 spheric pressure.   It is the pressure of
 the  air that prevents the  escape of the
 fluids contained in the  vessels; and if it
 be largely diminished,  hemorrhages are
 apt to occur from those  parts of the body
 where  the vessels  are  least protected by
 the  textures in which  they creep, as in
 the air  passages, and, indeed, in the mu-
 cous membranes generally.
   The  effect  of diminished atmospheric
 pressure on a part of the body is well ex-
 emplified by the application ofa cupping-
 glass.
  The  inconveniences  sustained  by as-
 cending lofty mountains, are partly owing
 to the  rapid passage from a  denser to a
 rarer medium.   Some, however, have af-
 firmed  that they,  in no respect, depend
 upon diminished pressure, but  upon the
 fatigue  induced by the ascent. Bouguier,
 Haller, Rudolph,  Meyer,  and others,
 are of this  opinion, and the  Abbe Fer-
 rara asserts, that none but invalids are
 incommoded on ascending to the summit
 of Etna.  Londe, too, affirms, that he has
 scaled the highest peaks of the Pyrenees,
 without experiencing any inconvenience,
 except  what arose  from  the  excessive
 cold, and that the acceleration of respira-
 tion  and circulation  ceased after resting
 for some time;  whence  he, likewise, in-
 fers,  that the effects are to  be ascribed
 solely to the violent  exercise of the as-
 cent  On  the other hand, we have  the
 testimony  of De Sayve,   De Saussure,
 Hamel, Raymond,  Von Humboldt, and
numerous  others, toshow that fatigue
  vol. n.           45
could have had little or no agency; and
what strikingly exhibits the accuracy of
their deduction is, that the same inconve-
niences were sustained by Gay-Lussac
in his celebrated  aerial voyage,  already
alluded to. The indisposition experienced
under  such circumstances,  is extremely
common in South America, and is termed
sorocco.   Dr. Meyen—a recent German
traveller—thus describes the effects pro-
duced  on his party, during an expedition
to the  mountains of Peru.  " We were
tormented  with a burning  thirst, which
no drink was able to assuage: a slice of
water-melon, which we had" brought with
us, was the only thing we could relish,
whilst our people ate  garlic, and drank
spirits, maintaining that this was the best
way to guard against  the effects of the
journey.  We kept on  ascending till two
o'clock in  the  afternoon.   We were al-
ready near the little ridge, which extends
W. S. W. from the summit of the moun-
tain, when our strength at once abandoned
us, and we were overtaken by the disease
sorocco.  The nervous feverishness under
which we had  suffered from the first had
been  gradually  becoming  worse  and
worse; our breathing became more and
more oppressed; fainting,  sickness, giddi-
ness, and  bleeding at the nose, came on;
and  in this condition we  lay a consider-
able time, until the symptoms grew milder
from repose, and we were able to descend
slowly."  (Reise um die Erde u.  s. w. in
den Jahren 1830, 1831,  and 1832.  Ber-
lin, 1834.)
  It is from the  feelings  experienced at
such lofty elevations, that  legitimate de-
ductions with regard to the effect of the
air at great heights can alone be drawn.
At lesser  elevations, the  uneasiness sus-
tained  may be so trifling as scarcely to be
felt by  the  robust; and hence the  testi-
mony of those who have  ascended the
Himala mountains, or the  Andes, is infi-
nitely more  satisfactory than that of the
traveller who has merely climbed to the
summit of the  Pyrenees,  the most ele-
vated point of which is not more than
10,722 feet, whilst the Chipea-Pic of the
Himiilas, reached by Captain Gerard, is
19,411 English feet high; and Humboldt,
on Chimborazo—the highest of the An-
des—attained a height of 19,374 English
feet.
  These facts exhibit the  inaccuracy of
the  idea of Cassini, that no animal can
exist at the height of 2446 toises,—15,640
English feet  The observers sent out to
measure the earth under the equator,
lived for a considerable time on the  sum- 
530                       ATMOSPHERE.  (Pressure.)
mit of Pichincha,—15,939 feet above the
level  of the  sea,  and consequently  300
feet  above the point mentioned  by Cas-
sini ;  and the same gentlemen, whilst en-
camped  upon the mountain,  frequently
observed vultures soaring at the height
of 1300 feet  above them, or  in an atmo-
sphere where the mercury of the  barome-
ter was below 14 inches.  The  remark of
Cassini was  founded on the presumption,
that the  atmosphere,  at the  height  of
15,640 feet is one-half rarer than at the
level  of the  ocean;  and on the fact that
if the air be suddenly dilated one-half un-
der the receiver of the air-pump, an ani-
mal, placed under it dies.   Such would
doubtless be  the  effect upon man, if the
density  were as suddenly diminished; but
we have multitudes of instances to 6how,
that there is, within us, a capability of re-
sisting injurious influences to a surprising
extent,  provided  the  system has  even a
short time for accommodating itself to the
new circumstances under which  it may
be placed.  Even the small period that
elapses, in the ascent of a balloon to this
giddy elevation, is sufficient  for the pur-
pose, and death, we have seen, did not re-
sult where the elevation, attained in this
manner, was even 6095 feet  greater than
that indicated by Cassini as  the  limit of
animal existence.
  The highest town  of any extent on the
earth is Potosi in  Bolivia—celebrated for
the mines in its vicinity.  It  is 13,265
feet above the level  of the Pacific ocean.
Two hundred years ago, it is said to have
contained 160,000 inhabitants,  but  the
number  is not now greater than  12,000.
The highest inhabited spot on this hemi-
sphere is perhaps the farm of Antisana in
Quito,  the elevation of which is 13,400
feet.  Yet the human family are capable
of subsisting at  these  lofty  elevations
with the same facility as amidst the arctic
snows,—when once habituated to them,
—inconvenience  being felt  by new  set-
tlers only, and even these, by the gradual
ascent,  have  the  different organs accom-
modated to the new external relations.
  We have  no observations to guide us
regarding the comparative frequency of
respiration and circulation in  those who
inhabit  such elevated  districts.  The  ef-
fect  of  a sudden  change from a denser to
a more rarefied atmosphere  quickens, as
we have seen, both one and the other, but
much of the effect probably soon subsides.
It is reasonable, however, to presume, that
the respiration is  permanently more rapid,
in consequence of the rareness of the at-
mosphere requiring  a greater number of
inhalations, or, in other words, a greater
quantity of air to produce the same effect
in supplying  the  wanta of the  system.
Nor are we better informed regarding the
disposition to particular diseases, occa-
sioned in the inhabitants of such regions,
or whether there are any that can be le-
gitimately ascribed to a permanent resi-
dence in  an atmosphere more dense, or
more  rare, than that at the level of the
ocean.
  From what has been already observed,
it will be  conceived, that a sudden transi-
tion from a dense to a rare atmosphere
must  be unfavourable for such as are lia-
ble to hemorrhage from the mucous mem-
branes, and especially from  that  of the
lungs; and it is presumable that it might
lay the foundation for serious  chest affec-
tions ;  but this could only happen where
the change  had been rapid, and consider-
able, and  it  perhaps could scarcely apply
to those who have been born and bred at
such elevations as the town of Potosi.  As
regards them, the remark of Rostan (Loc.
Cit.)  is more than doubtful,—that " in a
very rarefied  air,  thoracic  inflammation,
phthisis, aneurisms of the heart, and fre-
quent hemorrhages, ought to be met with."
Tourtelle  affirms,  that in 1768,  and in
1770,  the mercury continued at a great
height and epidemic inflammations of the
chest,  of  the most  fatal character, pre-
vailed ; and he adds, that the consumptive
and the asthmatic are always incommoded
by too  dense an  atmosphere. (Elimens
d'Hygiene, 3eme edit. I. 233.) The same
effect is ascribed by these writers to oppo-
site causes,  and the truth appears to be;
—that changes  in the density of the  air,
if not greatly above or below the ordinary,
and not rapidly induced, are not attended
with  any marked  effects  upon  human
health, and that in many instances, phe-
nomena are ascribed to this cause, which
are more  properly referable, perhaps, to
other meteorological conditions, existing
together with, or  independently of, baro-
metric changes.
   At  the level of the sea, in our climate,
the average height of the barometer  is
about 30 inches.  At the height of 23,000
feet its mean elevation is about 12.95, but
its height is different at different altitudes,
and therefore the  remark of Londe, that
the density of the air best adapted for hu-
man  health and longevity, ought not to
cause  the mercury to fall much under 28
French inches (nearly 30 English inches),
and that  an elevation of 2075 metres—
about 6800 English  feet above the level
of the sea—is unfavourable to health,  is 
ATMOSPHERE.  (Temperature.)
531
untenable.  The cities of Quito and Cuen-
za are at greater elevations than this, and
Potosi  at double  the  altitude.  The ele-
vated regions of Asia, however, afford us
most striking examples of the impropriety
of deducing general inferences of the kind
alluded to.   In the valleys  and ridges  of
the lofty Himala  mountains,   immense
tracts,  which according to seeming ana-
logy, ought to be entirely barren,  or per-
petually  enveloped in snow,  are richly
covered  with vegetation,  abound  in ani-
mals,  and are scattered  with villages.
(See Climate.)
   Even the sanitary depots, for those suf-
fering under the diseases of the lower and
hotter parts of India, are situated, in some
instances,  higher than the  point assigned
by Londe  as the limit to  human health.
 Dargeeling,  in  the  Sikkim  mountains,
330 miles from Calcutta, has been recom-
 mended  as a sanitarium.   Its height  is
about 7218 feet  above Calcutta,  and  its
 mean temperature is  calculated to be 24°
 below that of Calcutta, and only 2° above
that of London.   A convalescent retreat
 has also  been provided at Simla, a station
 among  the hills  between the  Sutledge
 and Jumna, near Subhatto,  and 7500 feet
 above the level of the sea.
   J 2.   Atmospheric  Temperature.  The
 temperature of the atmosphere has proba-
 bly a more extensive  influence in  modify-
 ing human health than its density.  The
 range within which life can be maintained
 is great ar*d its vicissitudes are numerous.
 In our climate, the changes will occasion-
 ally amount to  40° and upwards in  the
 twenty-four hours.
   The capability of existing amidst  the
 snows of the frigid zone,  or in the burn-
 ing equatorial climes, is one of the  great
 characteristics of the human race; and it
 is surprising to reflect on  the quantity of
 heat that  must be constantly evolved by
 him in the former case, to resist  the  ex-
 ternal cold.
   In the  temperate, and  the  colder re-
 gions of the globe, where the thermome-
 ter rarely or never attains the tempera-
 ture of  man,—that is, 98° or 100°,—the
 body must be constantly parting with its
caloric;  and where the spirit in the ther-
mometer has stood at 55° below the zero
of Fahrenheit's scale, as it did during one
of the  voyages  undertaken  by Captain
Parry in search of a north-west passage,
the  expenditure,  in  spite of appropriate
clothing, must have been immense.   It
would  seem, however, that in such cases
the  organs  of  calorification take  upon
themselves an increased action, and per-
haps if the temperature  of a resident in
these inhospitable regions were observed,
it  would be found that  the heat  of  his
blood is some degrees hotter than that of
the inhabitant of the more temperate, and
the torrid regions.  Analogy and observa-
tion lead to such conclusion. The quadru-
peds of the frigid zone have a  tempera-
ture higher than those of any other region
of the globe.   Captain Lyon found  the
temperature  of an arctic  fox,  recently
killed, to be 106^° Fahr., when that of
the atmosphere was —14°.  On the other
hand, the capability of resisting  high  ele-
vation  of temperature is great.   In  an-
other publication, the author has adduced
numerous instances of the  impunity with
which air, at a temperature of 300°,  and
upwards, has been breathed for some time;
but this is a temperature to which we are
not  liable to be  exposed,  except for pur-
poses of science or  of public exhibition.
(Human Physiology, p.  196.  2d edition.
Philada, 1836.)
   In Virginia,  the thermometer scarcely
ever rises to blood heat.  In  many parts
of the state there are a few days when  it
attains  to 94°, and  occasionally to 98°;
but in South Carolina it has been seen as
high as 115°, as well as in the Llanos or
plains near the Orinoco.  In Africa, the
mercury is sometimes seen at 125°, whilst
in British India it is asserted to have been
as high  as  130°.  The highest tempera-
tures of that region are met with in the
great Western  Desert,  and other sandy
districts at the level of the sea, or nearly
so,—as the Circars,  and the Lower Car-
natic.   Elphinstone observed  the ther-
mometer at 112° in  the  Western  Desert.
Heyne,  in the Northern Circars, saw the
mercury at midnight at 108°;  and at  8
A. M. at 112°.  This is probably the most
elevated temperature that has ever been
noticed  in any region, whilst —55° may
perhaps be regarded as  near the point of
greatest observed depression;  the  observ-
ed range of the thermometer, consistent
with prolonged  human existence, com-
prising, therefore, at least 185°.
   In those cases in which  the heat of the
atmosphere is  greater than that of the
blood, we observe a compensating power
exerted by the organs of calorification, so
that the heat  of the system is  but little
modified by it
   The human body is of  course capable
of being penetrated by  the caloric from
substances exterior to it precisely as those
substances  themselves;  but within  cer-
tain limits, it possesses the faculty of con-
suming, as it were, the  heat, and of re- 
532
ATMOSPHERE. (Temperature.)
taining the same temperature.   We have
elsewhere shown (Human Physiology, 2d
edit.  I. 92, and Elements of Hygiene,  p.
47.) that  even when the temperature of
the  atmosphere  is  not  higher  than our
own, we  experience the sensation  of un-
usual warmth, yet no caloric is communi-
cated to us.   The cause of this feeling is,
that we are  accustomed to live in  a me-
dium of a less elevated temperature, and
consequently to give off caloric habitually
to the atmosphere.
   In this climate, we are constantly part-
ing with  caloric, and in  order to diminish
the expenditure, and to obviate the  sensa-
tion of cold, we have recourse to clothing,
and, during the colder months, to artificial
warmth;  yet there is a range of tempera-
ture, in  which, clothed as  we are, no
sensation of  cold is experienced, even al-
though heat  may be disengaged from the
body to some extent  The comfortable
point  varies, however,  in  different cli-
mates and seasons,  and is greatly depend-
ent upon  the temperature which has pre-
viously existed.  In this climate, it  may
be placed, perhaps,  between 70° and 80°;
but if the thermometer has ranged as high
as 98°, or upwards, and has maintained
this  elevation for some time,  a depression
of 15°, or 20°, will  give an uncomfortable
sensation  of cold, whilst we often observe,
in spring, an elevation from 30° or  40° to
75° or 80° produce  an oppressive feeling
of heat. The arctic navigators, after hav-
ing lived  for  some days in a temperature
of 15° or 20° below 0, considered the air
mild  and comfortable when the mercury
rose to zero.
   We may consider, then, that it  is na-
tural for  man to be subjected  to a  con-
stant abstraction of caloric, and that his
organism  is  adapted accordingly; but if,
from any cause, the organs of calorifica-
tion  should become  deranged, so that ex-
ternal heat greater than that of the body,
could produce its ordinary effects by con-
duction, or radiation, or  both—as it does
on inanimate objects—so as to  raise the
temperature  twelve or fourteen degrees,
the individual would die.
  On  the other hand, if the abstraction
of heat from  the frame were  to be exces-
sive, so that the calorific agents could not
supply  caloric as rapidly as  it was ex-
pended, the temperature would fall; the
fluids would congeal, and, when the tem-
perature of the whole body was depressed
to 79°, death  would supervene.
  It  would appear, consequently, that the
temperature of the  animal body may be
lowered beyond the natural  much  more
than  it can be  raised,  consistently with
the persistence of vitality.
   Independently of all  other  considera-
tions, the elevated temperature of the tor-
rid regions of the globe appears to be po-
sitively detrimental to animal health. The
stimulation of heat and constant evapora-
tion by cutaneous and pulmonary trans-
piration, maintain  the  capillaries of the
intestines in a state of irregular erethism,
and disposed to assume a morbid condition
under favourable exciting influences.
  In this way, we account for the numerous
derangements in the mucous membrane
of the intestinal tube, which are so fre-
quent in warm climates and seasons,—di-
arrhoea, dysentery, cholera, &c, with those
universal attendants upon inflammation of
the upper portion of the small intestine,
—liver diseases.   These are so common,
that it is rare to meet with a case of fever
in tropical regions not accompanied with
bilious  derangement.   The excitement
prevailing in the lining membrane  of the
duodenum, into  which  the  biliary ducts
pour their bile, is propagated along those
ducts, and arouses the liver to inordinate
secretion, or produces other functional or
organic disease in that viscus.  This state
of irritation of the duodenum, induced, too
often, by undue quantity or quality of ali-
ment, is that of nine-tenths  of  the affec-
tions termed bilious. A person, after hav-
ing dined heartily on a substance difficult
of digestion,  is  affected with heartburn,
distension, flatulence, great  uneasiness in
the epigastric region, and constant eructa-
tion ;  yet although the cause is manifest
he prefers to have the symptoms ascribed
to a predominance of bile, rather than to
a circumstance, the belief in which would
tend to curtail him, in  the slightest de-
gree,  of his enjoyments.
  Fevers, dysentery, and hepatitis, or liver
disease  in some form, with every variety
of bowel  affection, may be regarded as
the diseases of hot climates, and produced
essentially by various irregular conditions
of the dermoid system,—in which we  in-
clude, the skin and mucous membranes.
  That  hepatic disease is capable of be-
ing induced by heat we have proof in the
animal  kingdom.  The  celebrated pates
de foies gras,  made  at Strasburg  and
Metz, and so  much esteemed, that they
are sent as far as Paris, Vienna, and even
to St Petersburg, are prepared from the
liver of  the goose, artificially enlarged by
means of heat   The geese  are crammed
with food; kept  from drink; nailed to a
plank by the webs of their feet, and placed
quite  close to the fire;  and  in due time 
ATMOSPHERE. (Temperature.)
tlie liver becomes greatly enlarged, owing
perhaps to the excessive elevation of tem-
perature diminishing the nervous energy,
so that  the  digastric muscle, which com-
poses the  corpus callosum or gizzard, is
unable  to act with the necessary  effi-
ciency,  and, for the same  cause, the due
secretion of the appropriate  gastric solv-
ent is not accomplished.  The food, con-
sequently, passes on into the small intes-
tine, and, by the correlation of functions,
the irritation  perpetually  excited by its
presence, during this state of cramming,
is communicated by the biliary ducts  to
the liver, so that hypertrophy is produced
in that organ.  But, howsoever excited,
the application of heat in this manner,
scarcely ever  fails to produce the condi-
tion of liver  so recherche by  the gour-
 mand.
   Similar remarks,  to those made on the
 effect of  an  atmosphere  of diminished
density on the  respiratory function, are
 applicable here.  YVarm air, being more
 dilated  than cool, contains  less oxygen in
 the same bulk, and consequently a greater
 number of inspirations is necessary to ef-
 fect the requisite  aeration of the blood.
 Such, at least would be the result if the
 temperature  were  to   change suddenly
 from a cold,  to a comparatively warm,
 point;  but it  seems probable, that under
 the  protracted influence of an  elevated
 temperature, the hurry of respiration sub-
 sides ; the point of indispensable aeration
 is depressed;  the lungs become  less ac-
 tive, and less oxygen  is  consumed, the
 consumption being always found  to  keep
 pace with the degree  of muscular exer-
 tion,—being, indeed,  by many distin-
 guished physiologists, considered  depend-
 ent upon it.   Certain  it is, that the  con-
 sumption of oxygen is largely augmented
 by muscular  exertion, when not pushed
 to the extent  of inducing fatigue. Seguin
 found it increased four-fold.
   The effect of an elevated temperature
 in diminishing the consumption of oxygen
 has been proved by experiments on  ani-
 mals.  Crawford  found, that a Guinea-
 pig, confined  in air at the temperature of
 55°,  consumed double the quantity which
 it did in air at 104°.  He also found, that
 the venous  blood, when the body was ex-
 posed to a high temperature, had not its
 Lai dark colour; but, by its florid hue,
 indicated,  that little change had  taken
 place in its constitution in the course of
 drculation.   In other words, the,  extreme
 arterial vessels, winch appear to be the
 immediate agents of secretion  did not P^
 eess  their wonted energy, but permitted
                   45*
                                   533

the arterial blood to  flow  into the veins
unchanged.   Now these vessels, it is pro-
bable, are largely under the nervous in-
fluence, which,  every circumstance  ap-
pears to show, is considerably depressed
when the body is exposed  to great heat
and the difficulty of breathing,  and sense
of suffocation supervening under such cir-
cumstances, are mainly, perhaps,  refera-
able, as M. Georget has suggested, not to
rarefaction of the air, but  to debility of
the inspiratory muscles, owing to the en-
ervating effects of the elevated tempera-
ture on the nervous system.  In this way,
we account  for the  great lassitude  and
yawning induced by  the summer heats;
as well as for the languor and listlessness,
and the indisposition  to  mental or corpo-
real labour, which are so characteristic of
those who have  resided for  a length of
time  in torrid climes.  How many indi-
viduals have sailed from their country to
the scorching presidencies of  British In-
dia, in the full exertion of  youthful ener-
gy—intellectual  as well as corporeal—
and have returned to  the land of their na-
tivity, after a lapse of some ten or twenty
summers, so thoroughly changed as hardly
to have one characteristic remaining, and
seeming to be devoid  of all power of ex-
erting either mind or  body. (See Climate.)
   To the young, and the vigorous, a mo-
derately depressed temperature is agree-
able  and  exciting.  The first effect is to
diminish  the circulation in the capillary
vessels of the surface; and to interfere,
somewhat, with the process  of cutaneous
calorification, so far  at least  as  regards
those parts  that are not  well protected
against the coldness of the atmosphere,
 by appropriate clothing; but reaction soon
succeeds, either spontaneously, or  aroused
 by exercise,  and an  agreeable glow fol-
 lows the state of diminished calorification.
 This excited action  at  the sentient ex-
 tremities of the nerves is appreciated by
 the brain, which responds to the stimulus;
 the play of the  nervous system becomes
 more energetic, and, consequently, every
 function  under  its presidency acts  with
 more than usual vigour.   Perception  is
 more acute; reflection more ready; and
 most of the nutritive functions are more
 energetically accomplished,  with  the ex-
 ception of  the cutaneous  transpiration.
 The urinary secretion  is,  however, so
 largely augmented as to  compensate for
 the defective depuration by the skin.
    Such  are the  effects produced by
 a  moderate cold;—for example, of one
 between  30° and 45°  of  Fahronheit's
 scale—provided the exposure has not been 
534
ATMOSPHERE. (Temperature.)
too long continued, and due exercise and
clothing have been  employed.   When,
however, the body is subjected even  to
this temperature, and  a fortiori to a low-
er, without the necessary endeavours  to
counteract its influence, the subcutaneous
circulation is impeded ; secretion  and ca-
lorification are retarded, or arrested; the
skin becomes  rough,  and assumes the
character of the cutis anserina or chair
de poule, and the blood circulates in great-
er quantity in the interior of the frame, so
that inflammatory or subinflammatory af-
fections are  apt  to supervene, especially
in the  air-tubes, the lining membrane  of
which, in consequence of the diminished
cutaneous exhalation,  and circulation, has
its  vessels more  engorged;—and hence
the different forms of bronchitis;—cough,
peripneumonia notha, winter  cough, &c.
—which prevail  during  the  colder sea-
sons, and prove so fatal to the aged espe-
cially.
   It was asserted by  Beddoes,—and ex-
perience has corroborated his  assertion,—
that during  the  coldest months, there  is,
in England,  regularly the greatest num-
ber of deaths amongst  those  above 60
years  of age; and Dr. William  Heber-
den, Jun.,—a learned and accurate ob-
server,—who published  some interesting
observations  on the climate and diseases
of London, has said, that one of the first
things which must strike every mind en-
gaged in the investigation of this  subject,
is, the effect of a severe frost on old peo-
ple.  " It is curious," he remarks, " to ob-
serve among those who  are  said in the
Bills to die above 60 years of age,  how re-
gularly  the tide  of mortality follows the
influence of this prevailing cause; so that
a person, used to such  inquiries, may  form
no contemptible judgment of the severity
of any of our winters, merely by  attend-
ing  to this circumstance."
   These views are somewhat applicable
to our own climate. We should not, how-
ever, be justified  in according with Bed-
does,  that "during the  coldest  months
there is regularly the greatest number of
deaths among those aged above 60, and
the  fewest in  the middle  of summer."
The latter part of the sentence is not in
accordance with our experience.   On the
contrary, next in fatality to  the  pulmo-
nary affections, induced  by the severity
of the winter's cold, we would  class the
disorders of the lining membrane of the
intestinal canal, occasioned  by excessive
heat, which are  highly dangerous in ad-
vanced life, owing to the exhaustion they
 occasion  in a frame whose elasticity has
 been worn out by prolonged exertion.
   The facts above mentioned should, how-
 ever, induce elderly individuals  to adopt
 every precaution, during winter, to keep
 the cutaneous exhalation and calorifica-
 tion—not now affected  as in youth—ac-
 tive  by appropriate clothing (especially
 when they are subjected to exposure), and
 by a well-regulated temperature  in  their
 apartments.  The mode  of accomplishing
 this object will engage us hereafter. (See
 Clothing.)  Nor is less attention  required
 in the  state of first childishness,—in in-
 fancy.  Direct observation shows, that the
 function  of calorification is less perfectly
 accomplished the nearer to birth;  and that
 the compensating power, which we no-
 tice  to be  possessed by the older child,
 and by the  adult exists to a limited ex-
 tent  only for some time  after birth,—the
 temperature of the infant rising, and fall-
 ing,  according to the  greater or less ele-
 vation of that of the medium which it re-
 spires,  or in which it is placed, and,  in
 this  respect, resembling somewhat tlie
 cold-blooded, rather than the warm-blood-
 ed animal.
   In this tender state, exposure to a cold
 atmosphere is apt to produce local irregu-
 larities in the action  of the vessels, and
 various congestive, or  inflammatory disor-
 ders, which the tender organism is not
 calculated to withstand,  and, accordingly,
 it is  found, that exposure to a cold atmo-
 sphere proves very fatal to infants not pro-
 perly protected  against  its deranging in-
 fluence.
   Except in such cases,  however,  a pure,
 dry, cold  air, invigorates the frame ; and,
 if we find,  that during the season  at
 which depressed temperature prevads, in-
 disposition is prevalent the circumstance
 may  be explained more  satisfactorily by
 other mutations in the  atmosphere,  in
 combination with diminished temperature,
 or alone.  To this, however, we shall have
 occasion to allude hereafter.
   When the temperature is still more de-
 pressed, than in  the case we have consi-
 dered, and  the  frame is not sufficiently
 protected  against its influence, very dif-
 ferent phenomena  occur.  Instead of an
 invigorating action, the  nervous  system
 becomes  torpid; the brain  ceases to be
 affected by impressions from  without and
 an  irresistible desire for sleep comes on,
 which,  if indulged, becomes the  sleep of
death, and is, perhaps,  one of the easiest
modes in which life departs from the body.
(See Cold.) 
ATMOSPHERE.  (Moisture.)
535
  "> 3.  Atmospheric Moisture.  There is
another condition of the atmosphere, which
—singly or combined with the  others we
have mentioned—exerts considerable in-
fluence over the functions.  We allude to
the Hygrometric.
  As air  possesses  the property  of dis-
solving water,  all liquid bodies, when ex-
posed to it experience  a certain degree
of evaporation;  the amount of such eva-
poration varying according to the  degree
in which  water is already contained  in
the air.
  It has been  a question with physiolo-
gists, whether  the air abstracts moisture
from  the  animal body as it does from in-
organic substances. They who think that
the cutaneous  and pulmonary transpira-
tions are  mere  transudations, or depend-
ent  upon  a physical  permeation of fluid
from  within the  appropriate  vessels  to
without, and  independently of all  vital
agency, believe in the affirmative; whilst
they  who regard those  transpirations  as
altogether vital, consider that no  such
physical effect can result  Others, again,
with more propriety, believe that the con-
dition of  the  external air may concur in
 modifying the exhalation, even if it be
 regarded purely vital.
   The supporters of the first opinion ad-
 duce the instances  of  fishes,  which, if
 taken out of their proper medium,  and
 kept for some time in the air, lose a con-
 siderable  portion of their weight by this
 kind of evaporation, or transudation.  M.
 Edwards affirms, that having endeavour-
 ed to prevent  evaporation by placing a
 cold-blooded animal in a moist atmosphere,
 and at a temperature equal to that of the
 animal, so as to reduce the  transpiration
 to  that which was accomplished organic-
 ally, or by the vital action of secretion, he
 found that the physical evaporation formed
 five-sixths of the  ordinary loss by trans-
 piration.   Adelon,   however,  objects  to
 any inference deduced from aquatic ani-
 mals being  applied  to  man;—"the for-
 mer," he  remarks, " are impregnated with
 water, and as soon as they are exposed to
 the air, permit it to transude."  But such,
 he affirms, is  not the  case  with man,  in
 whom it is necessary, that the  matter of
 transpiration should be secreted by appro-
 priate organs, and be deposited on the pul-
 monary and cutaneous surfaces,  ite  de-
 nies, also, that anything like physical per-
 meation takes  place in  the living body.
 In another work, however, (Human Phy-
siology, 2d edit I. 42.)  we have endea-
 voured* show, that the hying tissues are
 penetrable, and that both imbibition and
transudation take place in the living body.
This, we think,  is  indisputably proved.
But  even were we to grant the position
assumed by Adelon,—that the cutaneous
and pulmonary transpirations are produced
by vital agency alone, and in no respect
to be assimilated  to physical transudation,
a great agency in modifying the quantity
of these transpirations must be ascribed
to the varying condition of the atmosphere
as regards moisture.  If the air be dry,
its  power of absorption  is greater;  the
perspirable matter evaporates as soon as
it is secreted ;  but when the air contains
much  moisture,  the perspirable  matter
does not readily  evaporate, but accumu-
lates on the  surface in  a sensible state.
In the former case, we should expect the
activity of the  exhalants to be  increased
by  the ready removal  of the secretion,
and in the latter to be diminished, for op-
posite  reasons.
  It is not probable, however, that the
main effect is induced  in this way, but
that the  process is of  a more physical
nature,  and  that  the  body  parts  with
the  watery fluids, contained  in the  ves-
sels, by simple transudation, although we
are  not prepared to deny, that a part of
the  result may be produced on the secre-
tory vessels in the mode mentioned.
   From what has been remarked, it can
be  easily  understood  why,  in  a  warm
moist  air, we seem  to perspire more than
in  a hotter and  dryer, although we may
really be exhaling less.   It is asserted by
Schmidtmeyer,  that  in the  climate of
Chili, notwithstanding the very high tem-
perature in  summer,   the  perspiration
passes  off so entirely  in the  insensible
form, that during the most violent  exer-
cise, it might be doubted whether any
perspiration whatever exists.
   If the air be greatly charged with mois-
ture, especially during the heat of sum-
mer,—owing to a diminution of the cuta-
 neous  and  pulmonary  transpiration, the
 evaporation of which constitutes a cooling
 process, we feel  languid and listless, with
 an  indisposition  to  all  mental and corpo-
 real exertion.  This is the cause why we
 suffer little more during the hot summers
 of this  country, than in those  of Great
 Britain, where  the air  is always  more
 loaded with  humidity, although the ther-
 mometer may be 15° or 20° higher here
 than there.
    Again, when we are exposed to a moist
 temperature much  greater than that of
 the body, we may seem to  perspire pro-
 fusely, whilst the cutaneous moisture may
 be  chiefly owing to another cause. 
536                       ATMOSPHERE.  (Moisture.)
  In certain experiments instituted by Dr.
Geo. Fordyce and Sir Charles Blogden,
with heated air,  they found in a tempera-
ture of 260°  of Fahrenheit,  that  small
quantities of water  in  metallic vessels
speedily boiled, and that streams of mois-
ture poured down  the whole surface of
the body; but that  this  was merely the
vapour  of the room,  condensed by the
cooler skin, the temperature of which was
only raised a few degrees above the ordi-
nary  standard, was proved by  the fact,
that when a Florence flask,  filled  with
water of the same  temperature as the
body, was placed in the room, the vapour
condensed in like manner upon its sur-
face,  and ran down in streams.
   On the other hand, when the air is cold
and moist,—owing  to aqueous vapour be-
ing a better conductor of caloric than air,
the heat is  abstracted in greater quantity
from  the  frame, and we  feel  more  chilly
than  the  temperature, it would seem, is
calculated to explain; and therefore more
liable to have those disordered and irregu-
lar actions of the capillary system induced,
which give occasion to  different febrile
and inflammatory disorders.
   M. Edwards ascribes the uneasy sensa-
tions,  experienced  on  the tops of lofty
mountains, to the augmented  evaporation
from the  lungs,  produced by diminished
atmospheric pressure, and great dryness.
This great dryness of the air at lofty ele-
vations was appreciated by Garcilasso
de la Vega.  " It is a well-known fact"
he observes, "that the  Adelantado  Don
Diego de Almagro, on his march towards
Chili, when, as is probable, he was  led by
his guides over the highest plain of Ta-
cora, lost more than 10,000 Indians, 150
Spaniards, and a number of horses, all of
whom fell  a sacrifice to hunger,  thirst,
and this  disease.  The  soldiers in that
memorable  expedition  built themselves
walls of the dead  bodies of their com-
rades, merely to protect themselves against
the drying effect of the wind."
   But facts, as  M. Edwards judiciously
observes, connected with an excessive eva-
poration from the lungs, may be observed
in otlier than elevated regions.
   In winter, when, during a very  sharp
cold, an apartment is warmed  by means
of a  stove,  a painful sensation  is experi-
enced by many persons in the chest.  The
air, in  a frost, contains  scarcely any wa-
tery vapour, and the heat of the stove, by
augmenting the temperature of the air,
 increases its capacity for vapour, so that a
 much greater evaporation is produced than
 in summer.  It is  an old custom to place
upon the stove a vessel of water to remedy
the inconvenience, and the practice is at-
tended with advantage.
  It is probably by this abstraction  of the
moisture from humid bodies, that air acts
as an  irritant to wounded and ulcerated
surfaces (see Air), and the great improve-
ment which has taken place in the ma-
nagement of such cases has consisted in
carefully excluding air, the admission of
which  occasions  a  rapid  evaporation of
the moisture covering them, and excites
irritation in the vessels, whose office it is
to effect the reparatory process.
  The barometric and thermometric  in-
fluence of  the air is  exerted  with more
or less energy upon the animal frame, ac-
cording as  its hygrometric condition is
more or less considerable;  that is, accord-
ing as  it is  more or less dry or damp.
  We have seen that the sensations of
heat and cold, which we experience from
the air, are greater when the air is damp,
owing to the presence of  water between
its particles adding to its conducting pow-
er ; and lastly, that as the dissolving pow-
er of the air augments in proportion to its
dryness and temperature, its action upon
the fluids of the body must be less in a
moist than  in a dry atmosphere.
  It may be remarked, by the way, that a
moist atmosphere is better adapted than a
dry one for dissolving various  animal, ve-
getable, or mineral substances, which  are
susceptible  of volatilization.   We have
many  instances to prove, that volatilizable
substances  are sooner converted into the
gaseous state under such  circumstances.
Camphor is found to volatilize with much
greater celerity in damp situations, and
every  one  has noticed the fragrance of a
garden after a summer's shower.  There
are  certain bodies, too, which require the
presence of  moisture for  their escape.
Thus, the odorous particles of argillaceous
substances  are  quiescent,  until they  are
breathed upon, or, in other words, become
moistened  by the fluid from the lungs, or
by moisture of some kind, after which the
mineralogist readily recognizes their char-
acteristic odour.
   Every one must have noticed how pow-
erfully the stench of putrid ditches is con-
veyed to the  olfactory organs in summer,
previous to rain, when the air becomes
charged with moisture; and  how readily
offensive substances are detected in a fog
by the same sense.
   The agency of moisture is, doubtless,
also concerned in the conveyance of the
various emanations from the soil, that pro-
duce endemio disease.   It has long been 
                        ATMOSPHERE.

noticed, that  whilst the  inhabitants of a
plain, on the  level of a marshy land, have
escaped those diseases that are known to
be produced by the emanations from such
land,—or by malaria (q. v.), as it has been
termed by the Italians,—those dwelling on
neighbouring elevations have suffered ex-
tensively.  Observation  would  seem to
have  shown, that this malaria is some-
what heavier than atmospheric air; but
as watery  vapour is  incessantly  exhaled
from  the surface of the earth under the
influence of solar heat and as this vapour
possesses so little specific gravity, it takes
up the miasmata along with it, and, un-
der  favourable  circumstances, they im-
pinge on these  elevations.
   The same  reasons apply to the commu-
nication of the  matter of contagion, which
would appear to be modified in its activity
by the degree  of moisture in the atmo-
sphere influencing its solubility and vola-
tility; but on this  topic our evidence is
not quite as satisfactory.   The same may
be said of epidemic  influences, of which
our ignorance  is  unhappily so  profound.
It may be remarked, however,  as  some
corroboration of this  view, that  the Har-
mattan,  a wind which blows  periodically
from  the interior of  Africa  towards  the
Atlantic Ocean, and  which is character-
ized by its extreme dryness, is asserted to
put an end to all epidemic and contagious
affections—even to smallpox; and it is
6aidtiiat at  such times, infection is  not
easily communicable by art.  We shall
find,  hereafter, that humidity modifies the
action of atmospheric electricity on  the
animal body, as well as the electrical con-
dition itself.
   } 4. Atmospheric Vicissitudes.   It  has
been already seen, that in the varying at-
mospheric conditions, which have been
considered, the system has the power of
accommodating itself to  the changes, pro-
vided they are not too extensive or sud-
den.   But if the mercury were to vary at
once  from 28 to 31 inches, or conversely,
it is difficult  to say what might be the ex-
tent of the effects of such sudden vicissi-
tude.  Or, again, if the temperature should
suddenly rise from — 55° of Fahrenheit,
to -f  130, as  a  natural consequence of this
rise the barometer would fall,  and from
these  combined causes—even  from  the
vicissitude of temperature taken singly—
man might cease to exist.
   Vicissitudes in the hygrometrical state
of  the  atmosphere  would  probably be
borne with the greatest impunity.
   It can rarely happen, that these vicissi-
tudes  in the  barometric, thermometric,
 (Vicissitudes.)                     537

or hygrometric conditions of the air, are
experienced singly.  It has already been
seen, that as we ascend in the air, the at-
mosphere necessarily becomes  lighter, the
mercury of the barometer  consequently
descends, and, at the  same  time, greater
and  greater coldness  is experienced ac-
cording to the elevation, so that if we are
ascending high  mountains we ultimately
attain  the regions of perpetual congela-
tion.   We have seen, also, that at very
great elevations, the  air is much dryer,
and  that inconvenience is  actually sus-
tained from this cause.  High up in the
atmosphere, we  have,  consequently, a
combination of a low  state of  barometric,
thermometric, and hygrometric conditions.
   Warm air,  again, being more expand-
ed, the  barometer sinks in it whilst a
larger quantity of aqueous vapour  can be
held in the  invisible state than when the
temperature is lower.
   These facts show, that the different at-
mospheric modifications, which we have
considered,  may  be   variously  circum-
stanced so as to  give rise to much of that
peculiarity which we notice  in different
climates, and to the various mutations ex-
perienced in the air  of the same district
of country.
   Vicissitudes  in  temperature are  the
most appreciable  by  our senses, and to
them,  consequently, our attention is most
frequently directed.  A  rapid alternation
from heat to cold is felt the most  disa-
greeably, and we are disposed to refer
numerous morbid conditions  to it, espe-
cially  if the cold be attended with damp-
ness, which it is sure to be, if the vicissi-
tude has been very sudden.
   During the state  of  warmth, a large
quantity of vapour may be retained in the
air in  an insensible form, which becomes
apparent if the temperature suddenly sub-
sides to an unusually  depressed point
   Robust individuals may experience such
alternations without  detriment;  but the
delicate,—they  who are liable to internal
affections on  slight irregularities,—often
suffer greatly.   It has been  supposed, that
much  of this effect is owing to a sudden
check  to perspiration, and this may ac-
count for the mischief in many cases, but
unless the  change be remarkably rapid,
the  system will generally  accommodate
itself, so that the  depuration, previously
accomplished  by the skin, may take place
to a considerable extent from the urinary
organs; for we  have already seen, that in
the  winter months  this depuration ex-
ceeds  the cutaneous, whilst the contrary
obtains in summer.  Thus, the air may 
538                     ATMOSPHuKtt

continue, as it  often  does in  winter, in
this climate, for days together, largely be-
low  the freezing-point  and yet no evil,
under ordinary precautions,  may result
from protracted  exposure to it.
   It  does  not  indeed,  appear probable,
that  many  of the  maladies so often as-
cribed  to  depressed temperature  or to
taking  cold, are owing to mere diminu-
tion in  the  general cutaneous exhalation,
but  rather,  that they are ascribable to lo-
cal irregularities of the  capillary system,
between all the parts of which there is
such an extensive and intimate sympathy,
that  if one part be irregularly affected,
another portion  of the system, more  dis-
posed than the rest,  owing to inappre-
ciable circumstances,  to assume  morbid
derangement becomes implicated.
   The probability of some evil, resulting
from getting the feet  wet,  is proverbial;
yet  the  effect,  immediately produced by
exposure, involves but a slight extent of
surface.  Still,  if twenty  people  be ex-
posed to this cause  of disease, upwards of
two-thirds will probably  be attacked with
inflammation  or   irritation somewhere.
One  may have  one form of catarrh; an-
other may  have a second; another in-
flammatory sore throat; another pneumo-
nia ;  another inflammation of the  bowels,
and so on;  according as the capillary sys-
tem  of one part, in the particular indivi-
dual, is more liable, at the time,  to take
on an increased action than the rest.
   It  has been generally asserted  by  wri-
ters, that a sudden vicissitude from  heat
to cold  is likely to affect the bowels by
driving in  the perspiration, and occasion-
ing  it to settle on the  mucous membrane
of the  intestinal tube.   This does not ap-
pear to us to be good philosophy, although
the  fact of diarrhoea  supervening under
such circumstances may be indisputable.
   We  have seen, that the  mucous mem-
branes  essentially  resemble the  skin  in
 function, but they differ greatly in one re-
 spect.  The cuticular covering of the skin
 impedes tlie absorption of substances  from
 without, whilst the mucous membrane of
 the intestinal canal has the important of-
 fice  of absorbing all substances possessed
 of the  necessary  degree  of tenuity.  It
 is more an absorbing than an exhaling
 membrane.  It is probable, therefore, that
 where  a bowel-affection results from ex-
 posure to cold, under the circumstances
 mentioned, the  excited  action of the ex-
 halants is caused by the lining membrane
 of the  intestines sympathizing with the
 irregular action of the  cutaneous capilla-
 ries, so that tlie  membrane is not  in  a
 ( Vicissitudes.)

simple state  of healthy exhalation, occa-
sioned by the driving in of the cutaneous
transpiration, but actually labours under
inflammatory excitement  or irritation ;—
for such is always present to a greater or
less  extent in these cases,—produced in
the same manner as where a  distant or-
gan becomes  irritated in consequence of
an irregular  action of the capillaries of
the feet  in the case assumed above.
  It need  scarcely  be  remarked,  that
these effects, as well as all those that are
produced by  atmospheric  vicissitudes, af-
fect the feeble, and the convalescent  and
those debilitated, and irritated by previ-
ous evacuations or disorders,  more  than
the healthy.
  Halle, according to Bricheteau, was
in the habit of referring, in his lectures,
to the case of a physician, who was so
imprudent as to expose himself to a vicis-
situde of 29° of temperature from warm
to cold, after having been violently acted
upon  by a  powerful  cathartic.   "The
functions of the skin were  suddenly ar-
rested, and he died the next day of in-
flammation of the bladder."   Such cases
are not, however, singular.  They are of
every-day occurrence, and  the observa-
tion  of every individual could  enable him
to adduce many  of the kind.
   During the winter season, we frequently
pass, even in a state of perspiration, from
a heated atmosphere at 80°, or upwards,
to one of 32°, on  leaving a crowded as-
sembly,  and  often  without  adopting the
necessary protection against the cold; and
many a  victim  has recorded  the danger
of such a transition to  the delicate; yet
it is  surprising that  the  mischief is not
even more extensive.  There seems to us
to be much less  danger, in these cases, in
passing into the open air, whilst the  sys-
tem is strongly heated, than after we have
waited, as is the  common practice, until
we have become cool.  Whilst the skin is
hot  and dry, the whole capillary system
is in a state of activity,  and if we pass
into the cold, whilst this activity exists,
we are better able to resist its depressing
effects;  and, accordingly, every one must
have noticed, that he  has suffered  less
under such  circumstances than when he
has waited until the organs of calorifica-
tion have begun to act with less energy.
   Let it be borne in mind, that these ob-
servations do not apply  to that state in
which the activity of the vessels has be-
gun to  subside, in consequence  of per-
spiration, which is a cooling process, hav-
ing been established.  In such a case, the
heat is  undergoing resolution, and if we 
expose ourselves to cold,—owing to that
cause as well as to the irregular capillary
action,  apt  to be  excited  by cold  and
moisture,—we have disease induced much
in the same way as it is  occasioned when
the feet are exposed to those agents. The
disease  is  not however, excited by the
check given to the general sensible per-
spiration, but  is owing to irregular local
action of capillaries, which, as we have
already  said, is one of the most  common
causes of morbid conditions of the various
structures.
   That  a sudden check,  given to sensible
perspiration, provided there  be,  at  the
game time,  exalted action of the  capilla-
ries, is not  of  itself likely to produce dis-
ease, provided the check be general,  is
proved  by the  effects of the Russian va-
pour-bath, of which Dr. Traill, of Liver-
pool, has recently  given a  description,
from personal  observation and experience.
(See Batlis.)
   But  although vicissitudes from heat  to
cold are generally regarded as most fre-
quent sources  of disease, they cannot take
place from  cold to heat with perfect im-
punity;  indeed, in certain cases, we ob-
serve the  most  unpleasant effects pro-
duced,—from  exposing a frozen limb, for
example, to the  influence  of heat.   In
such a  case, the limb is  in a state of tor-
pidity ;  and if it be now subjected to ex-
ternal heat the vessels,  continuous with
the  obstructed capillaries, have their ac-
tion excited; inflammation results at their
living  extremities,  and  the  congelation
becomes converted into irrecoverable mor-
tification.
   "Woe to the man," says  Larrey (Op.
Cit. IV. 134.), in his description of the
unfortunate campaign to which we have
previously  alluded, "benumbed by cold;
whose animal  functions  were nearly an-
nihilated, and whose external sensibility
especially was extinct if he suddenly en-
tered too warm a chamber, or approached
too close to  the large fires of the bivouac.
The more prominent parts,  benumbed, or
frozen, and  at a distance from the centre
of the circulation, were  struck with gan-
grene, which  supervened on the  instant
and  developed itself with such  rapidity,
that its progress was sensible to the eye;
or the individual was instantaneously suf-
focated  by  a kind of turgescence, which
appeared to attack the  pulmonary and
cerebral systems.  He perished as in as-
phyxia.   In this  way died  the Pharma-
cien-en-chef of the guard,—M. Sureau.
He had  arrived at Kowno without acci-
dent except that his strength was dimm-
!. (Vicissitudes.)                    539

 ished through cold and hunger.   An asy-
 lum was offered him in a very warm room
 in the pharmacie of the hospital.  He had
 not been  many hours,  however, in this
 new atmosphere,  before his limbs, which
 had lost all sensation, became tumefied,
 and puffy, and soon afterwards he expired
 in the arms of his son, and of one of his
 colleagues, without the  power  of utter-
 ance.  Individuals were often noticed to
 fall stiff dead into the fires of the bivou-
 acs ; and every one who approached near
 enough to heat the frozen hands  and feet
 was struck with  gangrene, wherever the
 cold had annihilated the vital properties."
    When the effect of depressed  tempera-
 ture upon the extremities is to a less ex-
 tent,  diminishing merely the calibre  of
 the vessels, and they are  exposed, under
 such  circumstances,  to the heat of the
 fire, increased  action takes place in the
 unaffected extremities of the blood-ves-
 sels that are  continuous with the affected
 capillaries; blood is forced into them in
 undue quantity, and inflammation results,
 constituting the  affection known  by the
 name of Chilblains (q. v.).
    It need scarcely be said, that  a sudden
 and  rapid change from cold to heat may
 develope irritations and inflammations in
 various structures, according to their pre-
 disposition, at the time, to be morbidly af-
 fected ;  and that  hemorrhages, and other
 affections, occasioned by heat  and dimin-
 ished atmospheric pressure, may  be the
 result in such cases.
    When  the  air,  from  being  dry,  be-
 comes moist those affections are apt to
 be developed, which  are the  product  of
 moist air;  and  these,  it will be recollect-
 ed, differ according as the moisture is ac-
 companied with  elevation  or depression
 of temperature.  No  inconveniences re-
 sult from  a  sudden  vicissitude  from a
 moist to a dry air, so far as mere  moisture
 is  concerned.  It  has been already shown,
 that at  high elevations much inconveni-
 ence  is experienced from this cause, but,
 in such case, the  dryness is extreme, and
 there are deranging influences of a baro-
 metric and thermometric kind operating
 at the same  time.  The remark is appli-
 cable only to  the  ordinary  vicissitudes
 from  moisture to dryness, which are ex-
 perienced  in any given locality.
    It must not be presumed,  that these vi-
 cissitudes  in  the  physical characters of
 the air,  when within the bounds of mode-
 ration, are detrimental to man.  Without
 the changes effected by the seasons, it is
 obvious  that  animals  would be deprived
 of the support they derive from the vege- 
540                      ATMOSPHERE.  (Electricity.)
table kingdom;  and, it is probable, if we
lived in  the  state of perpetual  spring,
which has  been imagined, by poets, as
best adapted  for  animal  existence  and
comfort °ur enjoyments would be much
less than they are at present.   How mo-
notonous  would seem the succession of
day after  day!  How devoid should we be
of  that buoyancy,  and  elasticity,  which
we experience, when the moisture of a
foggy morning is dispelled  by the rays of
the  sun,  and  all  is life and gaiety!  It
may be said, indeed, that we should expe-
rience none of that languor, and lassitude,
which a heavy, lowering atmosphere in-
duces.  This  is true: but all  our plea-
sures are  relative, and the same intensity
of  comfort  could  not  exist if all were
sameness.   We should become  lazy, and
listless; worn out with ennui, or depressed
with  melancholy;  and  as the stimulus
would be wanting, which the constant
mutation  of the physical agents around
us is perpetually applying to the frame, so
as  to  maintain its various functions  in
energetic activity, we might probably be
liable to  more derangements than affect
us at present, under all our atmospheric
vicissitudes.
  These  very mutations,  indeed, have
been considered by one  of the  most dis-
tinguished  of  British philosophers (Sir
Humphry Davy) as  the  cause of  the
mental  activity,  which  he considers  to
characterize his countrymen. " Of all the
climates of Europe,"  he remarks, in his
" Consolations  of Travel,"   " England
seems to  me most fitted for the activity
of the mind, and  the  least suited  to re-
pose.  The alternations  of a climate,  so
various and rapid, continually awake new
sensations;  and the changes in the sky,
from dryness to moisture, from the blue
ethereal to  cloudiness and fogs, seem to
keep the nervous  system  in a constant
state  of excitement   In the  changeful
and tumultuous climate of England, to be
tranquil is a labour, and employment is
necessary to ward off the  attacks of en-
nui. The English nation is pre-eminently
active, and the natives of no other country
follow their objects with so much  force,
fire, and constancy."
  The vicissitudes of the  temperate re-
gions of the globe are so numerous, and
often so unexpected, that it is  impossible
for us to guard well against  their injurious
effects.  Some persons endeavour, as they
say, to  fortify their children from  early
infancy, so that they may resist them, or
be less affected by them.  It need scarcely
be said, that all undue clothing,  and resi-
dence  in  heated  apartments, without
change, must be liable to  the  objections
we have urged against a monotonous con-
dition of the  physical influences around
us; but, at the same time, it is not every
infant that will bear the plans  employed
by  some parents to harden it;—such as
bathing every morning in cold water; ex-
posure  to  the air  at all  temperatures;
light  clothing, even when the air is cold,
&c.  Many an  infant  has fallen  a vic-
tim to  this persistence  in error.   Two-
fifths  at least of mankind die of  acute
diseases, and a large majority of  these
are induced  by exposure to  cold.  If,
however,  the  infant  is  habituated to
daily  tepid bathing, and ablution,  for a
time,  and the temperature of the fluid be
gradually depressed, until cold water alone
is used ; and  if it be comfortably clothed,
with flannel next its skin; and be  sent
into the fresh air, whenever the weather
is serene—even if the temperature should
be somewhat depressed—it  may be accus-
tomed to exposure  as far as is prudent,
and better adapted for bearing with impu-
nity the vicissitudes of the weather,  than
where it is immured under the circum-
stances just referred to.
  Similar remarks apply to the adult, who
can expose himself to cold air with impu-
nity, under ordinary precautions, provided
he does not accustom himself to dwell in
too heated apartments,  and keeps the
house whenever the thermometer is much
lower than the  medium heat of the cli-
mate.
  5 5.  Atmospheric Electricity.    The
electrical condition  of the  atmosphere,
and of the animal  body, has,  by  many
writers, been  considered to be intimately
connected  with animal  health,  and the
feelings are certainly much affected  by it.
Death even takes place, if we are situated
so as  to be connected with the discharge
from a sufficiently-charged electrical cloud.
Many persons, too, exhibit a manifest dif-
ference in the performance  of their func-
tions when the air is highly electric, and
are apt to  suffer considerably from head-
aches, and from pains of various kinds to
which they may be  subject
  If the air  is very dry, and insulating,
whilst the clouds are high,  and at a great
distance from  the  earth,  all  electrical
communication  between the earth, the
living bodies attached to it and the clouds,
is  intercepted, and no  electrical pheno-
mena  are manifested.  Under  such cir-
cumstances,  partly  owing  perhaps to
these  conditions, and  partly also  to fa-
vourable barometric,  thermometric,  and 
ATMOSPHERE. (Vitiations.)
hygrometric conditions,  the  individual
feels full ot energy and elasticity.
  If, on the other hand, the air be charged
with moisture,  it becomes  a  good  con-
ductor of electricity, and there is a more
free communication  between  the  earth
and the clouds.  If the communication is
very extensive,  the equilibrium of elec-
tricity takes place insensibly, and without
any apparent phenomena, except  that a
degree of languor and  lassitude  may be
experienced, unconnected with muscular
action, or disease.
  It; again,  the communication is not suf-
ficiently  complete, or not sufficiently ex-
tensive,  proportionally  to   the  electric
charge in the clouds, the  equilibrium  is
established by violent explosions,  which
give occasion to thunder and  lightning;
and if an animal be situated in the line
of passage of the electric fluid, it may
 experience such a  shock as will destroy
 it.  Independently, too, of the  electricity
 which  is communicated  by conduction,
 bodies  are affected by induction,—in such
 sort, that if a cloud, highly charged with
 electricity, approaches  the earth within
 the requisite distance, the earth becomes
 charged with opposite electricity.
  It is not  improbable but that the vary-
 ing conditions of the atmosphere,  as re-
 gards its electricity, may, in conjunction
 with the  other states that we have  consi-
dered, be very largely connected with the
prevalence of particular diseases,  which
affect districts of country during particu-
lar  years and  seasons, and not  during
others.  We shall  see, hereafter,  how-
ever, that our knowledge of epidemic dis-
eases, or  those which, in the present state
of science, are referred to modifications of
the constitutio aeris, is extremely limited.
(See Epidemics.)
  Dr. Forster,  who, in his various es-
says on atmospheric phenomena, has much
that is interesting and logical, with much
that is fanciful,  is of opinion,  " that it is
not  the heat, nor cold, nor dampness, nor
drought of the air,  which is  chiefly con-
cerned  in producing disorders, nor the
sudden transition from one to another of
those states; but that it is some  inexpli-
cable peculiarity in its electric  state."
The pain, felt in limbs which have been
formerly broken, previous to  a change of
weather,  and the disturbed  state of the
stomachs  of many  persons,  before and
during  thunder-storms, are sufficient he
thinks, to warrant such  a conjecture.  It
may be so, but we do not see why the di-
minished  pressure of the  air, in  these
eases, with  its altered  hygrometric con-
  vol. ii.         46
541
 dition, might  not explain  the indisposi-
 tions to which he alludes, as well as those
 other  pains, and aches, which are pro-
 verbial, as indicating some  change of the
 weather, when the air has been previously
 dry, and dense,—such as rheumatic pains,
 tooth-ache, shootings, and  tenderness of
 corns, &c.  (See Electricity.)
   { 6.  Atmospheric Vitiations.  The air
 is liable to various admixtures which ma-
 terially modify its action upon the animal
 economy, and  to vitiations  from different
 chemical changes effected in it by  na-
 tural causes.   The changes produced in
 the air by respiration and combustion, and
 the injurious effects experienced by ani-
 mals, when restricted to a confined space,
 from the generation of carbonic acid thus
 formed, have already been  noticed. (As-
 phyxia, p. 489-491; see also, Carbonic acid
 gas.)   Even  in  large apartments, when
 crowded, artificially  heated,   and well
 lighted, inconveniences, as hurried  re-
 spiration  and circulation, giddiness, &c,
 are not unfrequently experienced from
 the presence of the gas just named. The
 lights  burn  dimly; the healthy and  the
 strong  feel  oppressed, whilst  the  more
 feeble and delicate swoon; but owing to
 the facility  with which the  air of our
 apartments is  changed,  it cannot  often
 happen that it is so  much deteriorated
 as  to  occasion   fatal  results, or  even
 serious inconvenience.  Yet as Dr. Hodg-
 kin has suggested, the constant and fre-
 quent  application  of  the   cause  cannot
 fail to  produce  injurious effects, and it is
 not improbable that the unhealthy appear-
 ance of the poor, who have  large families
 crowded together in small and  ill-con-
 trived  chambers, and more  especially the
 sickly  6tate  of their children, originate,
 in  part in its  agency.  (Lectures on the
 means  of promoting   and preserving
 health, &c, by T. Hodgkin, M. D.  Lond.
 1835.  p. 15.)  All living  bodies, when
 confined in a restricted space, deteriorate
 the air so much as to  render  it unfit  for
 the maintenance of the  healthy function.
 If animals be kept crowded together in
 ill-ventilated apartments,  they speedily
 sicken. The horse becomes  attacked with
glanders;  fowls  with pep;  and  sheep
 with a disease peculiar to them, if they be
 too closely folded.
  Jail  fevers, hospital fevers, camp fevers,
 all  owe their origin  to  the deteriorated
air  of these places;—deteriorated by the
formation of carbonic acid gas, with the
various animal exhalations and excretions,
with which  the  neighbourhood  of the
body must necessarily be imbued, where 
542
ATMOSPHERE. (Change of.)
thorough  ventilation is impossible.  (See
Malaria.)
  The atmosphere sometimes contains an
admixture of carburetted or sulphuretted
hydrogen gases,  both  of which  exert
a lethiferous influence on the animal sys-
tem.  (See Hydrogen gas.)
   The  air is apt also, to be loaded with
emanations from animal  and  vegetable
substances  in a  state of decomposition,
and these occasionally act in a morbific
manner;  giving rise to typhoid and other
affections.  There are also  many trades,
—such as those  of the gutspinner,  the
hartshorn manufacturer, the dealer in cats'
and dogs'  meat — technically called a
cracker—which are carried on in putridi-
ty ; but we shall  endeavour  to show,  un-
der another head (see Malaria), that  the
admixture of such emanations with  the
air does not affect public salubrity to such
an extent as might be imagined; although
the nervous, and the delicate, before they
become accustomed to the offensive odours,
may be more or  less disagreeably  im-
pressed.   The same may  be said of  the
butcheries,  dissecting-rooms, and  ceme-
teries.
  In many occupations, too, the air is  apt
to be vitiated  by mineral emanations, and,
in others, minute particles—animal, vege-
table, or mineral—are mixed with it,  en-
ter the lungs, and occasion  the peculiar
effects of those substances on the system;
or irritate the lungs in a chemical or me-
chanical manner,—but the consideration
of their effect on health will fall  more
properly under another head.  (See Occu-
pations.)
  We have yet to attend to those condi-
tions of the air,—totally inappreciable by
endiometric researches,—which give  oc-
casion to  epidemic, endemic, and conta-
gious diseases, and on which, unfortunate-
ly,  the  information we possess does  not
enable us to pronounce very definitively.
  The medical  profession have adopted
three terms to express their leading  ideas
of the causes  of diseases that affect  large
portions of the community, and are mani-
festly connected  with the air,  situation,
or community.
  Those causes that seem to be seated
wholly in the atmosphere, and  affect a
more or less considerable extent of coun-
try, unconnected with locality, are said to
be epidemic (q. v.); those  that are  con-
nected with locality only, are called en-
demic (q. v.), and  such as are  produced
by some emanation from an individual  la-
bouring under a similar disease are said
to be contagious (q. v.),—the diseases  re-
 sulting from those respective causes being
 termed epidemic, endemic, or contagious.
 Now, it will be obvious, that these causes
 may not act singly in all cases, but may
 be,  and frequently are,  combined.   For
 instance, there may be something in the
 locality, connected with a favouring state
 of the atmosphere, which  may occasion
 one  place to be insalubrious, whilst others,
 in the immediate  vicinity,  are  entirely
 healthy.  (See Localities.)
   Again, there  may be a constitution of
 the atmosphere favourable for the exten-
 sion of a disease, which is unquestionably
 contagious; or the causes of the exten-
 sive  spread  of such disease may  be of
 an epidemico-contagious character.   (See
 Contagion.)
   In all cases of endemic  disease there
 must be some modification of the  atmo-
 spheric condition, or of the  air of the lo-
 cality ; but such  modification, as we shall
 find  (see Malaria, and Endemics), has, in
 every instance, escaped the  researches of
 the  chemist, material,  as it unquestiona-
 bly must be.  These  failures do no more,
 however, than indicate the imperfect con-
 dition of chemical analysis.   That certain
 agents exist  in  the air is sufficiently
 shown by their effects,  and the day may
 arrive when we shall be enabled to detect
 them.
   On epidemics, as on endemics,  the
 discrepancy of writers sufficiently  ex-
 hibits the want  of fixed ideas.  Whilst
 some  refer  them  to  excessive  atmo-
 spheric heat,  others have ascribed simi-
 lar affections to cold.  Dryness, and  mois-
 ture, and opposite states of electricity,
 have also been invoked  to account for the
 same phenomena. Nor are our ideas more
 fixed with  regard  to the circumstances
 that favour  the spread  of contagious dis-
 eases, and to the constituents of any ema-
 nation from  the subject  of any contagious
 disease.
   }  7.   Change of Atmospheric  Influ-
 ences.  We have already referred to the
 fanciful  notions,  entertained by certain
 writers, on the subject of medium tempe-
 rature, and attempted to show, that it was
 neither well adapted to vegetable nor ani-
 mal existence.  It is  probable, indeed, as
 was  then remarked, that the different ba-
 rometric, thermometric, hygrometric, elec-
 tric,  and other vicissitudes, when within
 due  bounds,  are actually conducive  to
 health.
  Who, that has breathed the deteriorated
air of the crowded city,—less subject cer-
tainly, to thermometric vicissitudes than
that  of the  country, and deficient in the 
ATMOSPHERE. (Change of)
543
intensity of light to which the rural resi-
dent is perpetually exposed,—has not ex-
perienced  the cheerful,  invigorating  ef-
fects ofa short visit to the pure air of the
country, where  all the physical circum-
stances of the atmosphere, which are sus-
ceptible of modification, are changed 1
   What is  this but a vicissitude!  Yet
how advantageous the results!   The spi-
rits are exhilarated;  nervous depression,
produced by monotony, rapidly disappears,
with the ills dependent thereon; and  all
is buoyancy  and  elasticity, where languor
and  lassitude before predominated.  The
civic "etiolation" or blanching, marked
upon the  countenance vanishes, and the
ruddiness of rude health usurps  its place;
the appetite becomes augmented, and the
powers of nutrition are largely increased,
—as is indicated by the increase of weight
 which follows a sojourn, ef even a week
or two, in a  pure, salubrious region.
   A great deal of the effect is  produced
simply by change of air, or by the altered
feelings produced by a modification of the
different atmospheric influences; so that
 the change  from a better to a  worse  air
 has even been found serviceable. In Edin-
 burgh, the  inhabitants of the  most airy
 parts of the New Town frequently send
their children — when  labouring  under
 hooping-cough,—to the Cowgate, a  filthy
street which runs at right angles  under
one  of the largest thoroughfares of the
Old Town;  and  in  which, at  a certain
hour of the night the inhabitants eject all
the  offensive  accumulations  from  their
houses,  to be washed away by the waters
of the reservoirs, let on for the purpose.
   In all diseases, in which the  affection
appears to be kept up, in some  measure,
by habit and especially in those that im-
plicate the nervous system, change  of  air
is proverbially beneficial,  and, in this,  all
observers  acquiesce.  The multitudes  of
valetudinarians,  who annually leave their
habitations to visit the watering-places of
this country and of Europe, and who  re-
turn to their homes in the enjoyment  of
health, and  full  of confidence in the vir-
tues of the waters, near which they may
have resided, and  of which they may, or
may not  have  partaken,  are strikingly
confirmative of the position.  It is proba-
ble, indeed, that  a great portion of the sa-
lutary effects ascribed  to  the springs is
dependent upon  change of air, and other
extraneous  circumstances.  Long belore
the citizen of our Atlantic towns reaches
valetudinarian  finds himself almost  re-
stored during the journey—fatiguing as it
is—through the mountain regions, which
have to be crossed before he reaches the
White Sulphur Spring, in  Green Briar
county.  A  large  number,  too,  of  in-
dividuals, cannot drink that water with
impunity, and  who are consequently in-
debted for their improvement  chiefly to
change of air,  but  somewhat, also, to va-
ried scenery, and  society, and  to greater
regularity  of living,  perhaps, than  they
have  been  accustomed  to.   In  making
these  observations, we do  not mean to
affirm, that  mineral  waters—as  in  the
case of the valuable spring  in question—
niay not be important agents, occasionally,
in the cure of disease;  but, taking inva-
lids in general, we are satisfied, that more
is dependent upon  change  of air than on
the administration of the waters.  The in-
habitant of one of the Atlantic cities, or
indeed of any district to the east of the
Blue Ridge, removes  from  a hot,  malari-
ous country, to one which is comparatively
cool, and where all the diseases that are
common to hot and  malarious climates
are extremely  infrequent,  and  many of
them unknown.  The advantage is obvi-
ous. He escapes the diseases which would
almost inevitably have attacked him had he
remained, through the summer, in  his un-
healthy locality, and  hence the wealthy
families of lower Virginia are accustomed
to spend  those  months in the mountain
regions, in which they are  especially lia-
ble to disease in their own malarious  dis-
tricts.
  We can thus understand the reputation
acquired by  the Bath,  and  Matlock  wa-
ters ; the latter of which has scarcely any
solid  ingredient, and yet  what  crowds
flock to those agreeable retreats! to the
former, for the perpetual amusements, that
keep the  mind  engaged, and cause it to
react beneficially on  the bodily malady;
to the latter, for  the enjoyment  of  the
beauties of nature, for which Derbyshire
is so celebrated.  It is obvious,  that were
such waters bottled,  and sent  to a dis-
tance,  so that  the invalid  might drink
them  at his own  habitation, the  charm
would be dispelled.  Not many years ago,
amidst the  bubbles that were  engaging
the minds  and  the money of the English
public,  it was  proposed to convey sea-
water by pipes  to London,  in order that
the citizens might have the advantage of
sea-bathing, without the inconvenience of
the Alleo-hanv Soring* of Virginia, he has  going so many miles after it.  Had the
an earnest of the advantage he is about to  scheme been carried into effect,, the bene-
derive  from  change of air, and many  a  fits from metropolitan sea-bathing would 
544                      ATMOSPHERE.  (Change of.)
not have exhibited themselves in any re-
spect comparable to the same agent em-
ployed at Brighton or Margate.
  It would seem, that a mere  change of
the physical circumstances of the  atmo-
sphere, in which we are habitually placed,
is advantageous to the economy, and that
the vital powers  act with increased en-
ergy whenever we leave a  locality, to
which we have been  long  accustomed,
and where the functions are monotonously
executed, and pass to one differing essen-
tially from it: nor is  it always necessary,
as  we have seen,  that  this  difference
should  be  " essential."   Dr. Clark re-
marks (Influence  of Climate, 2d edit p.
234.), that  notwithstanding the uniformity
of  temperature, which prevails among
many of the West India Islands, the ef-
fect of a  change  from one to another is
often very remarkable in  improving the
health,—a fact  frequently observed, on a
large scale, among the British troops  sta-
tioned in the West Indies; and he consi-
ders, that one of the most powerful means
for diminishing the sickness among the
troops in that climate, would be to remove
them frequently from  one island to an-
other.  Such mutation would seem, also,
to be  indispensable  in our aliments (see
Food), where we  may have been accus-
tomed to variety,—and if we are restrict-
ed  to  one  only—however  nutritious  and
wholesome it may appear  intrinsically to
be—sickness is induced.
   Discrimination  is, of course, necessary
in prescribing  change of air as a  thera-
peutical agent  It is inadmissible during
the existence of acute affections in gene-
ral, but when the  violence of the disease
has passed away, and when the inflamma-
tion—especially if of the mucous textures
—has become chronic, we  have no means
to which we can  have recourse, that are
calculated to exert  a more beneficial in-
fluence, under proper precautions, than a
modification of the atmospheric influences
surrounding the  patient   Hence  it is,
that travelling, which combines change
of air with proper exercise, is so salutary
in chronic  irritation  of the mucous mem-
brane of the intestines, and of the bronchi.
Many of the cases, indeed, that have been
looked  upon as phthisis removed by this
course, have been cases of chronic bron-
chitis.  When the patient,—as Dr. Clark
properly  remarks,  in treating of  the
utility" of  change of air  during conva-
lescence, and the remark is equally ap-
propriate to the states of disease just men-
tioned—resides in a crowded city, or other
confined situation, the change is more ur-
gently called for, and, under such circum-
stances, many cases of severe disease oc-
cur,  complete restoration from which is
not effected without change of air.  " The
person, deprived of the  benefit  of such a
measure, attains only to a degree of health
inferior  to that which he enjoyed before
the occurrence of" his disease; and the re-
mainder  of his life is  often little  better
than a state of improved convalescence."
(Art.  Air, in  Cyclopadia of  Practical
Medicine.  London, 1832.)
  It is in such cases, that the inhabitants
of our cities,  convalescent from  acute dis-
eases, or labouring under chronic affec-
tions,  kept up, as  it were, by habit, find
so much  advantage from  a  trip to our
mountain regions, especially to the Trans-
Alleghany Springs, where, as  we have
seen, everything around them is  modified:
advantage is soon and signally apparent.
  Of the good effects of change of air in
hooping-cough, mention has already been
made.   These are most strikingly exem-
plified when it is had recourse to after the
disease  has continued for some time, and
the febrile symptoms, which so often at-
tend the  first period, have passed away.
The change from one room of the house
to another appears  to  be salutary, and
even, as we have before  seen, from a pure
air to one that is less so.
  In  every  form  of impaired digestive
function,  change of air can  be invoked
with  advantage,  and,  when  combined
with travelling exercise, the  benefits are
marked.
  A recent  writer,  in  pointing out the
decided  and  obvious influence  of travel-
ling on the digestive function, and, through
it, on the constitution  at large, goes so
far as to affirm his positive belief, that the
most  inveterate dyspepsia—where no or-
ganic disease has taken place—would be
completely removed, by a journey of two
or three  thousand miles through Switzer-
land,  Germany,  or any other country,
" conducted on the principle of combining
active with passive exercise in the open
air, in such proportions  as would suit the
individual  constitution,  and the previous
habits of life."  (Johnson, on Change of
Air, p. 30;  and  the Author's Elements
of Hygiene,  p. 156.)
   In  amenorrhcea,  and  in other states of
the uterine system, connected with atony,
the exciting  influence of new atmospheric
conditions, new scenes,  and  occupations,
are amongst our most valuable  resources;
and in dysmenorrhoea, become  inveterate
by habit, these influences will occasionally
break in upon the morbid catenation, and 
ATMOSPHERE.—ATOMIC THEORY.
545
if the female should marry, or, being mar-
ried, should be  fortunate enough to pass
one menstrual  period  without  suffering,
she may become pregnant, and the re-
sulting gestation may completely remove
the mischief,  by eradicating the morbid
habit.
  In most of the diseases  affecting  the
nervous system,  and especially in those
often characterized by great mobility, and
irritability,—epilepsy,  chorea, hypochon-
driasis, &c. — the new  impressions,  ex-
cited  by  change of  air,  society,  and
scenery, are strikingly useful, especially if
the diseases have been  connected with a
sedentary life in a confined situation.   In
all such cases, as Dr. Clark has  observed,
this is a remedy for which we have no ade-
quate substitute.  " But change of air,"
as  the same writer  judiciously  adds, " is
not more valuable as a remedy in the cure
of disease, and  its consequences, than as
a preventive of disease, more  especially
in childhood and youth.  At this tender
and susceptible period  of life,   the rapid
influence  of the  atmosphere in which we
 live,  in  deteriorating or  improving the
health, is very remarkable; a change of
a few weeks from the  country  to a large
town being often sufficient to change the
ruddy, healthy child, into a pale, sickly-
looking creature, and  vice versa.   The
comparative  influence  of a  town  and
country air on the  health of children  is
seen in a striking manner in the families
of the higher ranks  of society, who spend
a considerable part of every year in town.
Children  should never be reared in large
towns, when this can be  avoided;  and
when  unavoidable,  they should be sent,
during a  part  at least of  every summer,
 into the  country, which,  indeed,  is the
proper place for  children,  until  their sys-
tem has acquired sufficient strength to re-
sist the injurious effects of city life.  When
they cannot have this advantage, we  con-
sider it the duty of the medical attendants
of families  to  urge a  temporary annual
residence in the country,  as essential to
the health of children, more particularly
those who are delicate.  How many neg-
lect this  invaluable means of improving
the health of their offspring, who have it
in their power, and would willingly adopt
it were they aware of its importance!
So  strongly,  indeed,  are  we   impressed
with the value of this measure, from am-
ple observation, that we consider parents
resident  in towns, who have the  means
of giving their  family  the  advantage of
country air,  and neglect it, deficient in
one of their chief duties.   To  young fe-
                  46*
males, who, by the habits of society, are
much  more confined to the house than
boys,  a  temporary annual  residence in
the country becomes a  measure of still
greater importance, and  should be conti-
nued  at least to the full period of their
growth.  We have reason to believe, that
the  advantages  of  country air to the
young,  and delicate, are not sufficiently
appreciated by the profession, and we are
therefore anxious to call their attention to
it, that they may use their influence with
the public, upon  whose  minds,  if they
succeed in impressing  the  full value of
pure  air, they will be the means of con-
tributing greatly  to the health of the
rising generation."  Such has long been
our impression, and  for years we have
acted upon it wherever it has been prac-
ticable. Independently of the signal bene-
fits derived, by the young especially, from
simple change  of atmospheric influences,
the large  proportion  of children who die
under the age  of two years,  in  towns,
compared  with the  country,  sufficiently
exhibits,   that  the  air  of towns acts
upon them deleteriously, and hence the
necessity for moving them into the coun-
try,—during the heats of summer, espe-
cially,—when  the infantile mortality is
greatest.
   The above remarks apply to change of
air, abstractedly considered,—such as the
same  country or district is capable of af-
fording.   Under another head  (see Cli-
mate), the effects of a total and more per-
manent mutation of atmospheric influ-
ences,  on both the  healthy and  morbid
condition, will be canvassed.
   Bibliography.—The different writers on Hy-
giene.
                  Robley  Dunglison.

   ATOM.  (From  a priv.  and ttpva, I
cut.)  The ultimate or smallest particle
into which matter can be divided.   I. H.
   ATOMIC. Appertaining to atoms. I. H.
   ATOMIC THEORY.   In  chemistry
the theory which  maintains the existence
in matter of physically indivisible parti-
cles called atoms; and which explains the
laws of combination  by supposing that
the chemical elements unite by these par-
ticles when they  form  compounds.  The
laws of combination relate  either  to the
proportions  in  which  substances  unite
with one another, or  to the  proportion
which the different quantities bear to each
other,  in  which  the  same  substance is
found capable of uniting with some other
substance. The proportions in which sub-
stances  unite with one another are defi- 
546
ATOMIC THEORY.
nite, and not by insensible gradations, and
have  this peculiarity,  that they  may be
denoted by a series of numbers represent-
ing a succession of ratios, which are not
independent of each other but connected
throughout  like the different links of the
same chain. When these numbers denote
the ratio of the weights of the  constitu-
ents in what is considered a primary com-
bination, they  are  called equivalent num-
bers  or  chemical  equivalents;   because
they  represent  the relative   weights in
which the different chemical substances
combine with or decompose  each other,
and  are, therefore, in that sense  of  equal
value. They are sometimes called propor-
tional numbers, and combining weights.
The  ratios  of combination having this
equivalent property, are called equivalent
proportions.
  The equivalent numbers represent the
ratios in which  both the elementary and
compound bodies unite; but  the equiva-
lents of the compound bodies are erected
exclusively  upon  the  equivalents of the
elements as a  basis, and are regulated by
them. This will clearly appear when the
fact  is adverted to that the equivalent of
a compound is  merely the sum of  the
equivalents  of its elements; and that the
numbers obtained by this simple process
of addition  for any two compounds will
necessarily  represent  the proportion in
which such compounds will  unite with
one  another.   The equivalents  of com-
pounds  being  thus deduced,  it follows
that it is of chief  importance to ascertain
the equivalents of the  elements.
  It has been  stated above that  the laws
of combination relate also to  the propor-
tion  which the different quantities bear to
each other, in which the same substance
is capable  of uniting  with  some  other
substance.   To descend to particulars, it
is found that in not a few instances, the
same substance will form two  or,  more
combinations with some other substance
taken at a constant quantity;  and the re-
lation which the several quantities of the
varying substance bear to each  other in
its several combinations may be noticed.
Now it is found invariably that this rela-
tion  is a simple one, and may be denoted
by numbers which  have a simple ratio to
each other.  Thus, for example, the rela-
tive  quantities of the varying ingredient
which enter into  combination, supposing
two  combinations, may be as  1 to 2, as 2
to 3, or 3 to 5; or supposing  three com-
binations, as the numbers 1, 2, 3.  In all
these cases, either all the higher quanti-
ties  are multiples by a whole number of
the lowest quantity; or all the quantities
are multiples by a whole number of some
number.   To denote this remarkable re-
lation  in the numbers, expressive  of the
different quantities  of the varying  ingre-
dient uniting in several proportions, it is
Baid to unite in multiple proportions.
  The laws of combination may,  there-
fore, be said to embrace the two general
facts of equivalent proportions  and mul-
tiple proportions;  the  former denoting
the relation in quantity of different sub-
stances when combining;  the latter, the
relation of the different quantities  of the
same  substance in  its several  combina-
tions with another substance.  But  it may
be asked why have the numbers represent-
ing chemical combinations these remark-
able properties; why are proportions equi-
valent, and why are they multiple ?  The
answer to these questions leads at once to
the supposition that substances unite  by
certain particles or atoms which have dif-
ferent  weights, in  other words  to  the
adoption  of the atomic theory.
  The  more remarkable properties of equi-
valent  proportions are that they are ex-
pressed by numbers which have a fixed and
invariable relation to each other, and that
they form a  chain  of  ratios  connected
throughout  Now,  if it be supposed that
substances, when they form combinations,
unite by their ultimate particles or atoms
assumed to have different weights, the
same fixed relation and equivalent pro-
perty of the numbers denoting  the com-
bining quantities would obtain.  Thus  it
is found that hydrogen and  oxygen, to
form water, unite in the fixed proportion
of 1 to 8;  and if it be  supposed that, in
this combination, the ultimate particles or
atoms  of the  elements unite, they having
the relation in weight of 1 to 8; then the
relation of the quantity of hydrogen to the
quantity of oxygen  in any given portion
of water would be precisely the same as
that ascertained by experiment  It  is thus
shown that the supposition of an atomic
mode of combination satisfactorily explains
the remarkable properties of the equiva-
lent numbers;  while no other supposition
is sufficient to explain them.  Hence it is
reasonable to  conclude that  the  atomic
theory furnishes a true explanation of the
peculiarities observed in these numbers,
as denoting the proportions in which che-
mical substances unite.
  It may be  next proper  to inquire how
far the atomic theory is adequate  to ex-
plain multiple proportions, the  other law
of chemical combination already adverted
to.   Here  the remarkable property ob- 
ATOMIC  THEORY.
547
served is that the  different quantities in
which one substance will  combine with
another substance, bear a simple relation
to one another, called a multiple relation.
To adduce the simplest case of this kind,
let us suppose that oxygen, according to
its equivalent  number 8, unites the ni-
trogen, according to its equivalent num-
ber 14; and that in a second combination,
16 of oxygen unites with 14  of nitrogen.
From the explanations  already given, it
will be  understood that  8  and 14, being
equivalent numbers, represent respectively
the relative weights of the atoms of oxy-
gen and nitrogen. But the different quan-
tities in which oxygen combines with ni-
trogen in the two combinations indicated,
are represented by 8 and  16;  and it is na-
tural to inquire, why have these numbers
so simple a relation to each other!  The
quantity of oxygen in the  first combina-
tion  being 8, why is its quantity in the
second combination exactly 16, or twice
8, and not a little more or  a little less?
 Now the  theory of atomic  combination
 answers these questions in the most satis-
 factory manner.  The equivalent quantity
 of oxygen 8, represents the weight of an
 atom of oxygen.   If then  more than the
 atom of oxygen 8,  is found to unite with
 nitrogen in  the second  combination, the
 increase cannot be any fractional  part of
 8, without dividing an atom;  and  the di-
 vision of an atom,  from its very nature, is
 held to be impossible; but the increase
 may be the whole of 8, because that num-
 ber represents an entire atom; and hence,
 the quantity of the oxygen  in the  first
 combination being 8, its quantity in the
 second may be 16.   Here then the multi-
 ple relation of 16 to 8  is  fully explained
 by  admitting  that the 8  represents  the
 weight  of one  atom,  and  the   16,  the
 weight  of two; and the absence of any
 intermediate  proportions is  equally  well
 explained by the property of indivisibility,
 ascribed to an atom.  Thus then multiple
 proportions in chemistry are  satisfactorily
 accounted for by  supposing  combination
 by indivisible particles, or atoms.
   In the  foregoing remarks  we have en-
 deavoured to show that  all the peculiari-
 ties  observed  in equivalent  and multiple
 proportions are accounted for by supposing
 that substances  combine by  their atoms.
 Such a mode of combination, though uni-
 versally  admitted  by chemists as a just
 representation  of  the manner in which
 substances unite,  cannot,  in the  present
 state of science, be proved to take place
 Hence  the  explanation of  the  laws ot
combination,  that  they depend on  the
fact  that chemical  substances  unite  by
their atoms, is called the atomic theory.
  Subjoined is a table of the equivalent
numbers of the 54 elementary substances
at present known, taken from the last edi-
tion of Turner's Chemistry, and correct-
ed  by the  new  edition  of Berzelius's
Theorie des Proportions Chimiques, pub-
lished in 1835.  It will 6erve to give the
reader  a general  idea  of the numbers
which  express  the  experimental  com-
bining weights of the several  elements,
and which are generally supposed to re-
present the relative weights of their atoms.

     Aluminium.................... 13.7
     Antimony..................... 64.6
     Arsenic........................ 37.7
     Barium........................68.7
     Bismuth....................... 71.
     Boron......................... 10.9
     Bromine....................... 78.4
     Cadmium...................... 55.8
     Calcium....................... 20.5
     Carbon........................  6.12
     Cerium........................ 46.
      Chlorine.......................35.42
     Chromium.....................28.
      Cobalt........................  29.5
      Columbium....................185.
      Copper........................31.6
      Fluorine....................... 18.68
      Glucinium..................... 17.7
      Gold...........................199.2
      H vdrogen...................... 1.
      Iodine........................126.3
      Iridium........................ 98.8
      Iron........................... 28.
      Lead..........................103.6
      Lithium....................... 6.44
      Magnesium.................... 12.7
      Manganese.................... 27.7
      Mercury.......................202.
      Molybdenum................... 47.7
      Nickel.........................29.5
      Nitrogen  ...................... 14.15
      Osmium.......................99.7
      Oxygen........................ 8.
      Palladium..................... 53.3
      Phosphorus.................... 15.7
      Platinum...................... 98.8
      Potassium.....................39.15
      Rhodium...................... 52.2
      Selenium...................... 39.6
      Silicon........................ 7.5
      Silver.........................108.
      Sodium........................ 23.3
      Strontium .....................43.8
      Sulphur........................ 16.1
      Tellurium..................... 64.2
      Thorium......................59.6
      Tin ........................... 58.9
      Titanium......................24.3
      Tungsten......................94.8
      Uranium.......................217.
      Vanadium..................... 68.5
      Yttrium....................... 32.2
      Zinc...........................32.3
      Zirconium..................... 33.7

   These numbers merely express,the ra-
 tios  in which the several elements  com-
 bine ; and  hence any other numbers de-
 noting the same  ratios would be equally
 accurate.   This being the  case, it is ne-
 cessary to assume the equivalent number 
548
ATOMIC—ATROP A.
of some substance, and to deduce the other
numbers directly or indirectly from it.  In
the above  table, the equivalent number
of hydrogen  is  assumed, and fixed  at
unity, and  from it all the others are de-
duced.   Some chemists assume the equi-
valent of oxygen, and call it either one,
or one  hundred,  which  changes all  the
hydrogen numbers proportionally; but the
hydrogen unit is more  convenient, and
more generally adopted.   At one time it
was maintained that the equivalent num-
bers were  not merely expressive of defi-
nite  ratios; but that all the larger equi-
valents contained the smallest,  or that of
hydrogen, an even number of times; that
is, were exact multiples of its equivalent.
When this multiple  relation of the equi-
valents was admitted, it is easy to per-
ceive that the assumption of unity to de-
note hydrogen caused all the  other ele-
ments  to be  represented by whole num-
bers.  This rendered the numbers expres-
sive  of combining weights or  atoms  ex-
ceedingly simple; but unfortunately  the
multiple relation here referred to has been
proved to be unfounded.  Hence it is that
most of the  substances  in the above ta-
ble are  expressed by decimals, notwith-
standing the  hydrogen  unit is adopted.
It may be here  remarked that the dis-
proof of this multiple property of the equi-
valent numbers, in relation to that of hy-
drogen,  does  not interfere in the least
with the validity of the various  argu-
ments  which support the atomic theory.
  Although chemists  are unanimous  in
adopting the atomic theory as a  truth, they
are by no means agreed,  in all cases, as to
the number of atoms which the  combining
ratios represent.  Thus Berzelius admits
that hydrogen unites with chlorine in the
ratio of 1 to 35.42, but he conceives that
these two numbers represent severally two
atoms of each of the  elements in question,
oxygen being called 8.   Again, this che-
mist admits the ratio of 1 to 8 in the com-
bination of hydrogen and oxygen to form
water;  but his  theoretical view is that
the 1 represents two atoms of hydrogen,
while the 8 denotes but one atom of oxy-
gen.   These  observations are made  to
show that the equivalent ratios do not al-
ways coincide with  the  atomic ratios, as
adopted by particular chemists.  The na-
ture of* this work precludes any explana-
tion  of the theoretical grounds on which
certain chemists have rested, in adopting
atomic  ratios different from the equiva-
lent ratios.  It  may  be  remarked, how-
ever, that  to deny that the experimental
ratios form a true representation of single
atoms  of the  combining substances on
slight theoretical grounds, and to suppose
that these ratios represent in fact several
atoms of the different substances  which
unite,  has  the effect of creating  confu-
sion ; as it gives rise to variations  in the
atomic  numbers,  according to the notions
of different chemists,  who  nevertheless
may not differ in the least in their  ana-
lytical results.       -n,         -r,
 J                   t RANKLIN BACHE.

  ATONY.   (From  a priv. and tovos,
strength.)   Deficiency  of tonicity — re-
laxation, or a  diminution or loss  of the
elasticity of the tissues.   (See Tonicity,
and Debility.)                  I. H.
  ATONIC.  Appertaining to atony.

  ATRABILIARY.  An epithet given to
the  melancholic  and hypochondriac, by
the ancients, because they believed  that
the Atrabilis (q. v.) predominated in such
persons.                       I. H.
  ATRABILIS.  (From atra, black, and
bilis, bile.)   Black bile.  The  ancients
gave this name to a thick,  black, acrid
humour, secreted, according to  some, by
the pancreas, and to others, by the supra-
renal capsules.   To the influence of this
humour many  diseases were attributed,
especially  melancholy,  hypochondriasis,
and  insanity.   It is almost  unnecessary
to state, that the existence of such a  fluid
is  entirely hypothetical;  and that what
was termed  atrabilis,  is  the bile itself,
which in some diseases acquires a black
colour and  irritating properties.   I. H.
  ATRESIA.  (From a priv. and r^tof,
tube.)   Without  an opening.   Imperfo-
rate.   (See this last word.)       I. H.
  ATROPA. (Mat. Med. and  Bot.)
   Sex.  Syst. Pentandria monogynia. Nat.
 Ord. Solanese.
  Gen.  Ch.  Carol, bell-form.  Stam. dis-
tant.  Berry globular, two-celled. Eaton.
  The  genus Atropa  consists of but  few
species, which are eminently distinguish-
ed for their acro-narcotic properties, more
especially the A. belladonna  and A. man-
dragora.  They are generally herbaceous
perennials, growing in rich soil and damp
situations, and peculiar to temperate cli-
mates ;  Descourtilz, however, describes
an arborescent species found  in the West
Indies,  and which he states  is possessed
of so much  activity  as  to  paralyze  the
tongue  on merely  chewing  a  leaf of it
(Flor. Med. des Antill.  III. 119.)
  A. belladonna. Deadly nightshade.  Bel-
ladonne, Fr.; Wolfskirscher, Germ. 
ATROP A.—ATROPIA.
549
  Sp.Ch. Stem herbaceous; leaves ovate,
undivided.  Linnjeus.
  The deadly nightshade is a herbaceous
perennial,  indigenous  to many parts of
Europe and probably to some districts in
Asia, since  Ainslie  (Mat. Ind. I. 246.)
states that  it is well known in the Mogul
country and to the Arabians and Persians;
but adds that he has never 6een it in In-
dia,  It is usually found in situations where
the soil is rank, as in churchyards, and on
dunghills.  It has a thick, succulent root,
giving rise to  one  or  more  erect, round,
purplish, annual stems, attaining a height
of about three feet.  The radical leaves
are  sometimes very large;  those of the
stem are  alternate, ovate,  entire,  of a
dusky green colour above, paler beneath.
The flowers are large, nodding, solitary,
axillary; the corolla is of a dusky red co-
lour, and has a narcotic smell.  The berry
is large, roundish, at first green, but when
ripe, becoming of a shining black or dark
purple colour, containing many seeds, and
a violet-coloured juice,  which  is said  to
impart a rich and permanent stain to pa-
per, so as to  form a good pigment.
  Every part  of the  plant  is poisonous,
producing all the symptoms of the most
energetic acro-narcotics.   The leaves are
the only portion recognized as officinal.
These  are principally imported in a dried
state from Europe, though  of late  years
 the plant has been extensively cultivated
 for  medical  purposes  in various parts  of
 the United States, and more especially by
 the Shakers;  but  whether from want  of
 due attention in  drying the leaves, or from
 the effects of cultivation, it has not proved
 as  efficient as  the imported article.
   Although the deadly nightshade acts so
 energetically on man, it is eaten with im-
 punity by several animals, as the sheep,
 the hog,  and the rabbit, affording  addi-
 tional proof that the  effects produced  by
 poisonous agents  on the  inferior  races,
 ought  not to  be considered as  a  crite-
 rion of their action on man.  (See Bella-
 donna.)
    A. mandragora. Mandrake.  Mandra-
 gore, Fr.;  Abraun tollkraut. Germ.
    Sp. Ch. Stemless, scapes one-flowered.
 Linnaeus.
    The mandrake is a native of the south-
 ern parts  of Europe, growing in  secluded
 situations where the soil is rich and damp.
 The root somewhat resembles a parsnep,
 but is generally bifurcated,  and from two
 to  three  feet long.   It was formerly  in
 high repute as a narcotic, but is  now sel-
 dom or never used, though there is every
 reason to  believe that it possesses all the
 ualities of the belladonna in an increased
 egree.              R. E. Griffith.
  ATROPIA.  Atropium.   Atropine.—
These names have been given to  an al-
kaline substance detected by Brandes, in
1819, in the leaves of the belladonna; but
his experiments not having been confirmed
for many years, chemists became doubtful
of the existence of this body, until the in-
vestigations of Geiger and Hesse on the
one hand, and of Mein  on  the other, de-
monstrated the validity of the  discovery.
It should be  mentioned, however, that
Pauquy says he extracted it from the root
of the same plant in 1825, and  also states
that he procured it from the stems of the
datura, the  hyoscyamus, &c.   This  evi-
dently proves that the substance obtained
by him could not have been  pure atropia,
but was in all probability the salts of some
of the mineral alkalies.  Dr. Runge (Ann.
de Chim. XXVII. 32.) likewise indicated
a new method of obtaining it a few years
afterwards,  as did also Tilloy  (Journ. de
Pharm. XIV. 658.): the process  of this
latter chemist is, however, very defective,
and affords  an impure  product, though it
possesses considerable activity, for when
less than a grain is dissolved in an ounce
of alcohol, a few drops of the solution will
sensibly dilate  the pupil  of  the  eye.
Ranque and Simonin have asserted (Journ.
 Gen.  de Med.  No. 103. p. 36.) that this
alkali exists in the ethereal  tincture of
belladonna,  but  this  fact  is  denied by
Boullay and Henry.  (Journ. de Pharm.
XIV. 255.)
   Pure atropia is in white  prismatic crys-
tals, inodorous, soluble in absolute alcohol
and  sulphuric  ether.  Water at ordinary
temperatures dissolves only about tJ,, but
 takes up a much larger portion when aid-
 ed by heat.  This solution  has a disagree-
 ably bitter taste, and even when extremely
 diluted will act powerfully on the iris, di-
 lating it very promptly and durably.  It
 is  not volatilized at the temperature of
 boiling water, but on an increase of heat
 melts and  is transformed into empyreu-
 matic fumes.  It forms definite salts with
 the acids, the most readily crystallizable
 of which are the sulphate and acetate.
 Atropia is slowly acted upon by water and
 the  atmosphere at ordinary temperatures,
 losing its property of crystallizing.  The
 solution assumes a yellowish  colour, and
 furnishes an uncrystallizable residue, solu-
 ble in water in all proportions, and  having
 a  nauseous narcotic odour: it however is
 not  deprived of its poisonous properties,
 and is still capable  of forming crystalline
 compounds with the acids. 
550                         ATROPA.—ATROPHY.
  The best process for  its preparation  is
that of Mein.  (Journ. de Pharm. XX.
87.)  This, besides affording  a pure pro-
duct  is more  simple  than  the others.
Twenty-four parts of dry roots of bella-
donna,  obtained  from  plants  of two  or
three years  of age, are to be reduced  to
an  extremely fine powder; this is to be
digested in sixty parts alcohol 86° to 90°,
for  several days, then subjected to pres-
sure, and again treated  with  the  same
proportion  of alcohol as  before.   These
tinctures are to' be  united,  filtered and
mixed with  one part powdered lime, and
the  mixture  frequently  shaken  during
twenty-four  hours.   After being  again
filtered, diluted  sulphuric acid  is to be
added drop by drop, until in slight excess,
to precipitate the lime, which is to be re-
moved by filtration.  The tincture is then
to be  distilled till one half  has passed
over, and the  residue  diluted with six
parts of distilled water, and evaporated  in
a capsule by a  gentle  heat till  it is re-
duced to one third.  After cooling, a con-
centrated solution of potash is to be very
gradually added, as long as there is any
turbidness.   After any precipitate is re-
moved by filtering, the mixture is suffered
to stand, when it will present a gelatinous
mass containing white crystals of atropia.
The  fluid mother-waters are to be de-
canted, and  the residue  compressed be-
tween folds  of blotting-paper.  The im-
pure  atropia thus obtained is to be dis-
solved in five times its weight of pure al-
cohol, the solution  filtered, and six times
its bulk of distilled water added.  In about
twenty-four hours, crystals of atropia ofa
bright yellow colour will be deposited:
these are to  be washed with  a small por-
tion of  water, dried, and again  treated
as above, when the pure article  will be
afforded. Twelve ounces of the dried root
afford about twenty grains of pure atropia.
  Runge has also prepared this alkaloid
from the extract by pouring on a solution
of sulp. magnesia sufficient of a solution
of potash to decompose the sulphate, and
thus  forming  a  hydrate  of  magnesia
mixed with sulphates of potash and mag-
nesia:  to this,  extract of belladonna  is
added, and  the whole evaporated  to dry-
ness, reduced to powder, and  treated with
boiling  alcohol.   On  spontaneous evapo-
ration, crystals of atropia were obtained.
  Atropia or its salts have seldom been
employed, though  from their activity and
the certainty of their action,  they would
form  an advantageous  substitute for the
extract of belladonna, which is seldom  to
be depended upon, from deficient prepara-
tion, or the effects of age.  Dr. Reisinger
states  that they  are superior to the ex-
tract, in acting as direct sedatives, whilst
the primary effect of the extract is stimu-
lant.                  R. E. Griffith.
  ATROPHY.  Atrophia. (From o priv.
and -tpofn or tpsfn, nutrition.)  Defective
nutrition.  More  properly, Oligotrophy.
(From otoyoj, little, and rpo^, diminished
nutrition.)
  By some pathologists, the term atrophy
has been  restricted in its application to a
defect of nutrition, or wasting, merely lo-
cal, or confined to one or  more parts of
the body; the condition in which there is
a general wasting or diminution of the
volume of the organic solids, dependent
upon some serious disease influencing the
nutritive  functions,  being  designated by
the terms emaciation, marasmus, &c. In
an  anatomical and  physiological sense,
this distinction is inadmissible, since  atro-
phy, as it has been defined, may be either
local  or  general—affecting one or more
of the tissues, or  implicating the entire
assemblage of them at the same time.
  The animal tissues are developed and
sustained by the introduction  of nutritive
molecules, which are derived from the
aliments, and so modified by the  vital
powers of the organs, as to adapt them to
the nourishment and growth of the body.
This  is  effected  by the  conjoint agency
of the nutritive functions, and the mate-
rials thus elaborated are regularly depo-
sited  in  the  meshes of the tissues, there
to remain for a limited period, and then to
be  absorbed  into the circulation,   from
which they  are   either   thrown  off as
effete  matter, or after undergoing further
changes,  are  again  appropriated to the
purposes of nutrition.  Any cause disturb-
ing the  equilibrium and order  of these
functions, will derange the process of nu-
trition,  and  if such disturbance  be  of a
character to withhold or abstract the usual
supply of nutritive elements  from one or
more tissues or organs, the result will be,
a corresponding degree of atrophy,  or di-
minution  of  the  volume  of  the part or
parts affected.
  Atrophy presents itself  under a  great
variety of modifications,  dependent  upon
the number ano*  extent  of the  parts in-
volved, their importance  in the economy,
and  the  period of life at which the de-
rangement takes place.  The causes ca-
pable of inducing it are also multifarious;
yet they all operate by influencing either
the function of assimilation or that of ab-
sorption—in the one case interrupting the
deposition of the  proper quantity of nu- 
ATROPHY.
551
tritiye materials, and  in  the other occa-
sioning their too rapid removal from the
situations they should occupy.  A disturb-
ance  of these vital acts may occur either
during the  foetal or independent stages of
existence,  giving rise  in  the first case to
imperfect  and  anomalous developments,
and in the  second, to a diminution or pre-
ternatural wasting of the  mass of the or-
ganized solids.   We shall notice, succes-
sively, the  principal modifications of the
organs which give rise to atrophy.
   1.  Congenital defect of the formative
or plastic  energies.  The animal organ-
ization, in its  evolution,  passes through
several types and degrees of development
before it attains  the perfect form and ar-
rangement destined to represent its per-
manent condition.  The operation of the
formative energies may be suspended or
enfeebled at any one  of  these stages of
development and as this will give rise to
an interruption of the evolution  of the
organs affected, their growth will be sus-
pended, and at the period of  birth, they
will  exhibit the  imperfect type which
they  bore  when  the plastic forces  were
disturbed.  This law is exemplified in va-
rious forms of congenital atrophy, as, the
imperfect development of the whole  or a
part of the extremities;  defective  evolu-
tion of the kidneys and  supra-renal cap-
sules, spleen,  brain,  and other organs.
Under different degrees, it is  the source
of a large  proportion of the vices  of con-
formation which  are observed  in the ani-
mal organization, and under a still greater
extent it gives rise to all the monstrosi-
ties from defective  evolution.
   In many cases, there seems to exist an
intimate relationship between the develop-
ment of the nervous centres and certain
forms of congenital atrophy.   Ferrus re-
marks (Diet, de Med.  2d edit IV.  369.)
that amongst the great number of wretch-
ed inmates of the  Hospices Bicetre and
Salpetriere, who are degraded by a state
of idiotcy  or mental imbecility below the
level of their species, a state  of atrophy
and general paralysis is  of frequent oc-
currence.   A series of dissections  prose-
cuted,  first  by Amussat, afterwards by
Scipio Pinel,  revealed almost constantly
a dependence of the various forms of con-
genital atrophy upon some notable altera-
tion of the different portions of the nerv-
ous apparatus.  In many cases the brain
was  imperfectly developed—the convolu-
tions effaced, and the substance of the or-
gan  indurated.  Sometimes   a compact
mass or nucleus was surrounded by a por-
tion of the brain in a soft diffluent  condi-
tion.  The medullary substance predomi-
nated, and when an organ on one side of
the body was atrophied, the hemisphere
of the  opposite side of the brain was re-
duced  to  nearly  one  third its ordinary
size.  It is likewise   stated by Rostan
(Cours de  Med. Clinique, &c.  II.  122.
Paris, 1830.) that  in  idiots  affected with
congenital atrophy of  the extremities, the
brain always presents  manifest indications
of destruction on the  opposite side.   To
these facts may be added the assertion of
Serres (Analomie comparee du cerveau.
II.  125.) that there  is a  perfect corre-
spondence  between the evolution  of the
cervical and caudal protuberances of the
spinal  marrow, and the development of
the upper  and lower  extremities.  This
correlation is, however, far from being
constant.  A defective evolution,  or an
entire  absence of the nervous centres,
does not necessarily involve the  extremi-
ties  in  a  state of  congenital  atrophy.
Facts in sufficient number have been col-
lected, in which the organs, together with
the nervous  chords which  supply them,
were perfectly formed,  notwithstanding
the corresponding portions of the nervous
centres were  imperfectly evolved, or to-
tally absent.  (See Acephalus, and Anen-
cephalus.)  A very interesting illustration
of this law has been published by Lalle-
mand. (Observat. Path., &c. Paris, 1825.)
The subject of it  was an  anencephalous
monster, with entire absence of the spinal
marrow,  in which, notwithstanding this
defect there was  no  coexisting  atrophy
of the  limbs.
   2. Inadequate supply of blood, or  dete-
rioration of the properties of that fluid.
If the  opinion of Serres and Geoffroy
St. Hilaire, that the evolution of the or-
gans in the foetal state, proceeds in a strict
ratio with  their supply of blood,  be still
regarded in the light  of a  mere hypothe-
sis, it  must  be admitted that atrophy is
very often induced by an inadequate sup-
ply of nutritive  fluid, or  an alteration,
more or less considerable, of its qualities.
The causes  cutting off this supply  may
act either partially or generally. Amongst
them, may be enumerated constriction or
obliteration of the main artery of an or-
gan, an  impediment  to the free passage
of the blood through it occasioned by the
pressure of a tumour, thickening and in-
duration  of the surrounding parts, exten-
sive ossification and other organic lesions
of the  coats of an artery, a general state
of anemia, whether it proceed from  ex-
cessive losses of blood by hemorrhage or
otherwise,  or a general consumption of 
552                               ATROPHY.
that fluid, as  in phthisis pulmonalis and
otlier chronic  diseases;—finally, a priva-
tion of aliment the use  of such as is not
fit for the purposes of nutrition, and some
defect of the digestive  and assimilative
organs, inducing imperfect chylosis, per-
verted hematosis,  and a consequent in-
complete assimilation  of  the nutritive
fluids.
   Preternatural constriction or narrowing
of the principal artery leading to an or-
gan, by  interfering with  the proper sup-
ply of blood, gives rise to atrophy of the
part thus affected.  In a case of this kind
mentioned by Townsend (Cyc. of Pract.
Med. I. 214.)  the kidney was  reduced to
one half its size  by a diminution  of the
calibre of the emulgent artery; and he
cites another example,  on the authority
of Lobstein,  in  which  the spleen was
atrophied to the size of a filbert, the sple-
nic artery itself being so small as scarcely
to admit a bristle.  The influence resulting
from the application of ligatures to arteries
illustrates the same principle.  Under such
circumstances, atrophy  of the  parts fur-
nished by the tied artery ensues,  unless
an adequate supply of blood is furnished
by the collateral vessels.   Upon the same
principle, we occasionally resort to the liga-
ture with the  view of obtaining atrophy of
an aneurism, of fungous tumours  of the
antrum and eye, and of enlargement of the
thyroid gland; the obliteration of the main
arteries  leading to these parts by ligature,
being often sufficient to occasion the mor-
bid growth to collapse, shrivel, and occa-
sionally  disappear altogether.   The influ-
ence  of long-continued pressure is well
known.   It may  occasion atrophy either
by interrupting  the transit of the blood
through the main artery, or by prohibiting
 its entrance into the capillary vessels  of
the organ.   The extreme rigidity of the
arteries  in old age, often so far disqualifies
them  for the performance of their func-
tion, that they  are unable to  transmit a
sufficient supply of blood to maintain the
healthy nutritive functions. Extreme atro-
phy of the members  is  a very frequent
consequence of this defective  circulation,
and occasionally this process advances so
far  as to destroy the vitality of the part
as is  exemplified in dry gangrene.  A
 very  notable degree of atrophy  of the
 muscles is  often  induced by long repose,
 or a sedentary inactive  habit which,  by
 diminishing the supply of blood, impairs
 the nutritive  acts of those organs;—and
 in tabes mesenterica, phthisis  pulmonalis,
and other chronic diseases giving rise to
defective chylosis and hematosis,  or pro-
ducing inordinate  losses of the  nutritive
fluids, such an extreme degree of atrophy
is  sometimes developed, as to reduce the
individual to the condition of a walking
skeleton.  Portal, indeed, has asserted,
that in  those who die of phthisis by gra-
dual but protracted wasting, the blood is
almost entirely  consumed. (Traite de la
Phthisie Pulmonaire. p. 334.)   Finally,
atrophy may be occasioned by imperfect
sanguification, either  as a consequence of
an inadequate formation  of blood, or such
a  deterioration of the properties of that
fluid, as to render it unfit to maintain the
integrity of the  nutritive function.   (See
Blood, diseases of.   Marasmus.   Ema-
ciation, &c.)
   3. Impaired Innervation.   Of all the
causes of atrophy, a diminution or suspen-
sion of innervation probably exercises the
greatest influence.  This  is  well exem-
plified in the wasting of paralytic  limbs
consequent  upon injury of the brain, spi-
nal  marrow, or nerves.  It  is  probable,
however, that there is some difference as
regards the manner in which the atrophy
is produced, according as the defect in-
volves the  cerebrc-spinal,  or the gangli-
onic  portions  of the   nervous  system.
When  the  latter  is  affected, we are  in-
clined to think with Copland, that the
wasting is  in all  cases direct;  but when
the  defect  involves the  cerebro-spinal
nerves, it is probable, that in  some cases
at least the atrophy is indirect, and merely
ensues  in  consequence  of the  inactivity
of the muscles, which  naturally tends to
diminish  the determination of blood to
them, as exercise  always produces a con-
trary effect  This difference results from
the  more intimate relationship of the gan-
glionic nerves with  the capillary vessels,
their controlling influence  being indispen-
sable to maintain and regulate those mole-
cular changes of the nutritive fluids, which
are  immediately concerned  in  nutrition.
The cerebro-spinal nerves being more di-
rectly employed in the functions of rela-
tion, while they influence more or less the
acts engaged in the support  of the indi-
vidual, their participation in the  latter
class of functions  is far more limited than
that of the other nerves.
   There seems to be a notable difference,
as regards the period  at  which atrophy
ensues, after injuries of the several por-
tions of the nervous  system.  This differ-
ence is particularly conspicuous between
lesions of the brain and  those  of the indi-
vidual nerves.   Under  the latter circum-
stances, Townsend has correctly remark-
ed, that the wasting supervenes rapidly, 
ATROPHY.                              553
 whereas after injuries and diseases of the
 brain,  it is more  tardy in making its ap-
 pearance.  (Cyc. of Pract. Med.  1.214)
 We have seen  the truth of this  remark
 exemplified in several instances.   In  an
 individual who  received a severe contu-
 sion of the lower part of the  spine and
 the buttocks, in  falling from the mast ofa
 ship, the muscles supplied by the sacro-sci-
 atic nerve became paralyzed, and wasted
 rapidly; and in  a gentleman who had the
 lumbar plexus of nerves  wounded  in a
 duel, the muscles of the corresponding
 limb were reduced to one half their na-
 tural size in a short time.  In dislocations
 at the shoulder joint the elbow,  knee, &c,
 when  the  displacement  is not reduced,
 and the head of the bone is allowed to
 press on the adjacent nerves, considerable
 atrophy often ensues; and  a  similar con-
 sequence frequently follows distortion  of
 the  limbs  from rheumatic inflammation
 and other causes.  Sir Charles Bell has
 reported two cases of atrophy produced by
 a local disease  of a nerve.  In one, the
 muscles and ball  of the thumb were  so
 much  wasted,  that  the bones, and  the
 strings of the tendons over  them, might
 be felt quite plainly; and in  the other,
 while  the  forearm was firm to the feel,
 the  muscles of the arm were wasted and
 loose,  so as to render all the processes  of
 the humerus, from the shoulder to the  el-
 bow, quite distinct and the deltoid was
 also quite gone. (Append, to the Nat. Syst.
 of Nerves. American edit p. 221.)
   Atrophy succeeding an injury of a nerve
 sometimes continues through life.  In  an
 individual who died at the age of fifty-
 four, and who during childhood had  re-
 ceived a contusion of the crural and sci-
 atic nerves, Lobstein found all the parts
 of the  paralyzed limb—even the bones—
 reduced  to an extreme state of atrophy.
 The right  femur weighed only three
 ounces two drachms and a half, while the
 weight of the  left was  nearly  double.
 The gastrocnemius and soleus muscles of
 the  sound  limb  weighed  eight ounces—
 those of the  atrophied member only two
 ounces six drachms. (Traite <f Anat. Path.
 L  91.)   Townsend mentions the case of
 a  child, whose wrist  remained perfectly
 useless and reduced to one half its proper
 size, by a sprain which was neglected at
 the time it was received.
   Notwithstanding the  frequency with
 which  atrophy supervenes upon diseases
 and  injuries of the brain, such  a result is
 far from being constant. In several of the
old and infirm paupers affected  with para-
lysis, inmates of the Dublin House of In-
  vol.  ii.         47
dustry, Townsend remarks that he found
the  wasting of the  paralyzed limbs in-
considerable—and scarcely greater  than
would have occurred if the muscles had
been voluntarily kept in a state of inac-
tion for  the same length of time.  The
observations,  however,  of Amussat, Pi-
nel, and Serres, already referred to, prove
that the  influence of the brain over the
acts of nutrition is very great; and  it is
remarked by Loestein, that in some cases
of general emaciation,  the only  organic
lesions he could discover,  on opening the
body, were, a tuberculous induration of
the brain, or a development of a  fibrous
mass within its substance.  A similar con-
dition  of that  organ was discovered by
Tessier  and Esquirol, in several epilep-
tics  affected with atrophy. To the same
category of phenomena, may be referred
the  paralysis  and  consequent  atrophy
which sometimes attack those exposed to
the  influence of lead.   But whether the
wasting  proceeds from  the one  or the
other of these causes, it  should be borne
in mind,  that  it may be  either direct or
indirect.   It may result from  the suspen-
sion or annihilation of that influence which
the  nerves  exercise over the molecular
changes  of the tissues, in virtue of  their
intimate  association with the capillary
vessels,  or  it  may  be  merely a conse-
quence of the  suspension of volition and
muscular contraction, the  effect of which
is to diminish the determination of blood
to the part and thereby diminish  its nu-
trition.
  4.  Suspension of the Function of an
Organ.   The full  round and vigorous
muscle of those who are engaged  in  labo-
rious avocations, has often been a subject
of remark: — the opposite  condition of
these and other organs, in  individuals who
lead  a  sedentary life,  or who consign
themselves  to  a comparative state of in-
activity,  is not less conspicuous. The full
employment of an organ is indispensable
to ensure the perfect development of its
vital powers; constant  exercise being a
condition required to produce  that influx
of nutritive elements and nervous influ-
ence,  upon  which  its  powers depend.
Whenever  this state of  activity  is  ex-
changed  for one of repose, the organ be-
ing  divested  of  its  due  supply of  vital
stimulus, no longer attracts to itself the
usual quantity of blood and nervous influ-
ence ; its nutritive acts become impaired;
and it falls into a state of atrophy.   The
nutritive fluids, therefore, being diverted
into other channels, the vessels of  the af-
fected organ undergo a notable diminution 
554                               ATROPHY.
of size, and these changes may even ad-
vance  so far as to give rise to a total ob-
literation of many of the arterial  ramifi-
cations, or even of the trunks themselves,
precisely as takes place in the  obliteration
of the umbilical  arteries and  the  ductus
arteriosus of the foetus after birth. Almost
every period of existence affords exempli-
fications  of atrophy from a suspension  of
the function of an organ.   But in some
of these  cases, the change should be re-
garded as  purely physiological, since it
consists in  the wasting  or disappearance
of parts  that are no  longer  useful, and
which, if suffered to remain, would inter-
fere with the functions  of the perfected
organization.
   The umbilical  vesicle  of  the  ovum,
which constitutes the proper rudiment  of
the alimentary canal, becomes  useless and
wastes away, at  the expiration  of the
third  or fourth month of the  foetal exist-
ence;  the  allantoid  membrane,  which
forms  the  genito-urinary system, disap-
pears before the whole of the  organs are
perfectly evolved; and  in like manner,
the membrana pupillaris, which during the
period of foetal life, completely separates
the anterior from the posterior chamber
of the aqueous humour,  is destroyed be-
fore birth, so as to leave  no vestige of  its
previous existence.   Analogous changes
take place  after birth.  At this period, the
economy of the  individual undergoes im-
portant modifications, in order to accom-
modate it  to the  new state of existence
which it is destined to realize.   The um-
bilical arteries and veins, the ductus  arte-
riosus, and the  ductus venosus, being no
longer an essential part of the circulatory
apparatus,  contract upon themselves, be-
come impervious, and in the end fall into
such  a complete state  of atrophy,  that
their remains are rendered almost imper-
ceptible. The left lobe of the  liver, more-
over,  the  supra-renal capsules, and the
thymus gland, all remarkably  voluminous
in relation to the other organs  during the
period of foetal life, now undergo a notable
diminution  of volume, and some of  them
even  disappear entirely in the adult age.
Similar changes  are  observed in those
animals which at a certain period of life
are submitted  to a process of metamor-
phosis, to  adapt  their organs  to the new
modifications of action which  are neces-
sary in their economy.   The several spe-
cies of caterpillar, after they  have main-
tained that form  for  a definite time, un-
dergo a process of atrophy, by which a
portion of  their body  is  destroyed, while
from  the  remaining  portion,  the living
animal escapes under a new mode  of ex-
istence, denominated pupa  or  chrysalis.
The tadpole, also, which at first possesses
all the economy of a fish, when it  has at-
tained a certain degree  of development
has  its  gills and tail annihilated by gra-
dual atrophy, and  assumes  the type and
all  the  attributes of a perfect  animal of
its own species.
  Many examples of a similar character
are presented by the changes which the
organs undergo at subsequent  periods of
life, some  of which  are  the result of a
suspension  of function, while  others are
attributed to modifications of the vital acts
enfeebling  nutrition.   As  old age ap-
proaches, the energy of the heart's action
is abated, and the walls of that organ be-
come atrophied; the muscles contract fee-
bly,  and we often find them reduced to
mere shreds.  The  bronchial tissues, ac-
cording to Andral (Precis d'Anat. Path.
I. 185.), sometimes become  so  much di-
minished in size, that the pulmonary air-
cells are singularly rarefied and enlarged,
and  exhibit  an arrangement  similar to
that of the lungs of reptiles.   The testi-
cles in  advanced life are often absorbed
and converted into mere nuclei; the ova-
ries and mamma? become  contracted and
shrivelled; and the thyroid and  lymphatic
glands frequently have their volume very
remarkably  diminished.   We  have  seen
both testicles so greatly atrophied  in an
old man, that one of them was  not larger
than a common bean, while the other had
entirely disappeared,  leaving nothing but
a mere rudiment of  the fibrous coat and
the tunica vaginalis filled with  water It
is remarked by Riees (Bulletin de  la Fa-
cult. de Med. VI. 299.), that in old age,
the corpora cavernosa penis become  larger,
and the membranous partitions which in-
tersect  them, are so attenuated,  or re-
moved by absorption, that quicksilver tra-
verses them with great facility. The form
and volume of even the bones  are  some-
times altered by atrophy:—the long bones
especially become more slender; the neck
of the femur is shortened and has its di-
rection changed; the alveola? of the jaws
are wasted away, and the obliquity of the
ascending branches of the inferior maxil-
lary bone is increased. The length of the
vertebral  column  is  diminished; and the
cranial bones,  according  to the observa-
tions of Tenon (Mem. de rinstitut. 1.221.),
lose one fifth their weight In some cases,
indeed, the articular cartilages are par-
tially or entirely removed by atrophy,  so
as to suffer  the heads of the bones to rest
in  immediate  contact with each  other; 
ATROPHY.
555
and it has been remarked by Desmoulins,
that in old age, both the nervous chords
and  their  ramifications have a  volume
manifestly inferior to that of the  same
parts in early life, and that the  mass of
the brain, under the same  circumstances,
is less by one  fifth. (Journ. de Physique,
I. c. 442.  Lobstein.)   He hence infers
that the diminution of this organ involves
that of the cranium also, inasmuch as the
latter subsides to accommodate itself to
the former.  It  may be remarked, more-
over, that when an eye becomes unfitted
for the office of  vision,  it undergoes a
marked diminution of volume; and a case
is reported by Andral,  on the  authority
of Renaud, which indicates very clearly
the  influence of  the  suspension of the
function of an organ  in producing atro-
phy. One of the bronchial tubes of a mon-
key was nearly closed by  a large lymph-
atic ganglion filled with tuberculous mat-
ter,  and the  corresponding lung  was  so
much atrophied, that the walls of the tho-
rax  on that side  were contracted,  as  in
chronic pleurisy after the effused fluid has
been absorbed.
   5. Inflammation, and augmented nu-
trition  of adjacent  tissues.  It may ap-
pear strange to affirm, that increased irri-
tation  of a tissue sometimes  occasions a
diminution of its volume; yet several cir-
cumstances demonstrate that such is the
fact  It often happens when  a part is ir-
ritated  to a degree considerably beyond
that which is  compatible with the health-
ful exercise of its function, that its nutri-
tive powers are  impaired, or so perverted,
as to give rise to a considerable modifica-
tion of its volume.  Whether this depend
upon an inability on the part of  the capil-
lary vessels of the organ to attract an ade-
quate  supply  of blood, an incapacity of
the vessels to impress upon that fluid the
changes requisite  in the process  of assimi-
lation  resulting from  an  impairment of
their energies, an obliteration of the ca-
pillaries themselves by inflammation,  or
an  inordinate activity of the process of
interstitial absorption, by  which the nu-
tritive molecules  are  displaced  more ra-
pidly than  they can be supplied,  is diffi-
cult to decide. Certain it  is, that atrophy
from inflammation is  of frequent occur-
rence,  and there  are many  reasons  for
suspecting, that all the causes mentioned
may co-operate in producing the same re-
sult.  It is seen  in  the atrophy of the
muscles from rheumatism,  and especially
in glands which  have been for a long time
affected with chronic inflammation.  It is
strikingly exemplified in the condition de-
nominated nutmeg liver; and the spleen,
kidneys, and  pancreas,  often  exhibit a
similar diminution of volume, as a conse-
quence  of  chronic  inflammation.  Many
cases of atrophy, however, are  only indi-
rectly dependent  on  inflammation,  and
must be explained  by that law, in virtue
of which, a  preternatural augmentation
of the vital acts of one tissue,  is accom-
panied with a corresponding diminution
of the activity of some other.  Numerous
exemplifications of this  principle might
be cited.  Under the  preternatural irrita-
tion  of the organs  attendant on  chronic
diseases, the adipose tissue disappears al-
most entirely; the  muscles become small
and flaccid; the angles of the  bones sa-
lient ; the cellular tissue collapsed, as it
were, into their interstices; the membranes
attenuated;  and the weight  and volume
of the soft parts are sensibly diminished.
Inflammation of the mucous membrane of
the stomach and intestines is often attend-
ed with atrophy of  the muscular coat; a
disease  of  one kidney sometimes gives
rise  to a wasting of the other; and in dis-
eases of the articulations, the intense irri-
tation which implicates their structures,
occasions so  much wasting  of the  sur-
rounding parts, as to expose the  projecting
angles of the bones.  In  many cases,
moreover,  of protracted  disease of the
liver, the spleen is found notably atro-
phied ; and it  has been suggested by An-
dral, that  the condition of the liver, to
which Laennec has applied  the appella-
tion  of cirrhosis, is merely owing to an
atrophy of the dark, and  hypertrophy of
the yellow or  medullary granules of that
organ. We have often observed a similar
concurrence of the two modifications of
nutrition in the cortical and tubular struc-
tures of the kidneys,  as well  as in the
fibrous and  vasculo-glandular tissues of
the  spleen.   It likewise  often  happens,
that  while  the interstitial  cellular tissue
of an organ  becomes greatly  hypertro-
phied, the  other  textures composing the
part  affected are nearly displaced by atro-
phy.   This is  particularly manifest in the
several glands, and in the hollow organs;
as the alimentary canal, bladder, &c.  All
these consequences result from a portion
of that energy which is necessary to sus-
tain  the nutritive actions  of the tissues
being diverted from one or more of them,
to be consumed  upon others  more  in-
tensely irritated.
  It  will be proper in this place to men-
tion  another modification of atrophy, in
which the  natural  textures of an organ
are wasted, and have their place supplied 
556
ATROPHY.
by a preternatural generation of fat  This
is more particularly manifested  in the
muscular and glandular organs.   In  some
cases in which the muscular fibres are al-
most annihilated by atrophy, their inter-
stices become so filled with adeps, that no
diminution  of  volume can be  perceived.
There seems, indeed, to be a certain cor-
relationship between the atrophy of an or-
gan and the  inordinate development of
adipose substance; for  it very often hap-
pens, when a part falls into this state, that
it is completely surrounded by fat  This
coexistence is  frequently observed in the
heart the  kidneys, testicles, and several
other  organs,  when their substance is
wasted by  atrophy.   Andral,  by whom
this fact has been particularly noted, has
suggested  that the  atrophy of an organ
should be rather regarded as a kind of re-
trogradation of the process of nutrition,
than a diminution or suspension of its ac-
tivity.  This hypothesis, however, is alto-
gether inadmissible, inasmuch as the  co-
incidence in question, though of frequent
occurrence, is by no means constant  It
is not unusual for the same preternatural
accumulation of adipose substance to take
place, when the  corresponding organ is
in a state of hypertrophy.   This we have
repeatedly observed  in cases of hypertro-
phy of the heart, and the coats of the  large
intestines;  and it has been very correctly
remarked by Bouillaud (Diet, de Med. et
de Chirurg. Prat. III. 632. Paris, 1829.),
that  the colon is  often included in fat at
the  same time that  its tunics  are greatly
increased in thickness.
   6.  Preternatural  activity of the pro-
cess of absorption. It was long since sup-
posed by Cruickshank, that the absorbent
vessels, by having their activity increased
in a ratio disproportionate to that of the
assimilative powers, remove the substance
of the tissues, and thus produce a diminu-
tion of their volume. A similar view was
also entertained by Hunter, who regarded
these vessels as the modelers of the or-
ganic solids.   The  investigations of mo-
dern pathologists  have  rendered it proba-
ble, that the lymphatics,  in common with
the veins,  are  merely instruments for the
 transmission of the absorbed fluids, and
 that the act  of absorption is performed
 by the tissues themselves. It is at least
 highly probable,  that  this,  like  other
 vital  or organic acts,   may  be preter-
 naturally increased under particular  cir-
 cumstances; and if this  be admitted, it
 must be apparent that whenever such in-
 crease of the  process of absorption tran-
 scends the measure  of assimilation,  or of
the deposite of nutritive molecules in the
substance of the tissues, more or less atro-
phy will be the consequence.  It is possi-
ble, indeed, that some of the cases of what
has been 6tyled general atrophy, may de-
pend upon this cause; for we sometimes
find this condition existing when the most
careful  examinations after death do not
reveal any material  derangement  of im-
portant organs which could lead to such a
consequence. The known effects of iodine,
and some other agents, in promoting the
absorption  of the testes and mammae, as
well as the power of mercury to occasion
the disappearance of certain morbid pro-
ducts,  are favourable  to  the justness of
such an inference.
  The  condition  of the organs affected
with  atrophy  varies greatly  as regards
their form and volume—their texture, and
the relations of their several constituent
parts to each other.   In some cases there
is simDle but manifest wasting, amounting
to an aosolute diminution  of volume; as,
for  example, in atrophy of the muscles,
and many glands—in  the adipose, cellu-
lar, and other tissues; and  in some in-
stances, even in the hollow organs.   The
last, however, frequently undergo a great
degree  of  atrophy, without their  con-
figuration or volume being at all changed.
Under  these  circumstances,  there  is a
considerable abstraction from the mass of
the constituent molecules; but the cavi-
ties of  the organs are either augmented,
or their tissues are  so much rarefied, that
no  manifest decrease  of  volume can be
perceived, notwithstanding they may have
lost one third their ordinary weight. This
condition is often observed in atrophy of
the heart alimentary canal, uterus, blad-
der, &.c, the  walls of which  are some-
times so much attenuated by a diminution
or disturbance of their nutritive energies,
as to give rise  to a  complete perforation,
or such a degree of attenuation, as to ren-
der them liable to be ruptured by the na-
tural degree of distension to which  they
are exposed  in the  performance of their
functions.
   An organ may also be extensively  atro-
phied, yet undergo no diminution either of
weight or volume.  This occurs in organs
composed  of two or more tissues; as, for
example, the liver,  kidneys, spleen, &c.
Under  these circumstances,  while one of
the constituent elements undergoes a pro-
cess of atrophy, the others become hyper-
trophied ;—the accumulation of nutritive
molecules in the one, compensating for
their diminution in the  other.  Besides
this condition, there is another, in which 
ATROPHY.
557
the weight is diminished, but the volume
remains unchanged.  Some of the exam-
ples of atrophy of the hollow organs, al-
ready referred to,  are  of this kind, and
other exemplifications  are occasionally
furnished by the bones.  The compact sub-
stance of these structures is frequently so
much attenuated, as scarcely to equal one
or two leaves of paper in thickness (Lob-
stein. Op. Cit. I. 63.),  and the preterna-
tural fragility of  the  cylindrical  bones
which is observed in certain individuals,
is probably owing  to a  similar modifica-
tion of nutrition. Townsend, indeed, men-
tions a case, in which the femur of  an
adult was  so much atrophied internally,
that  it floated on  water, like cork,  al-
though its external surface presented  no
indication of such an alteration.  (Cyclop.
of Pract. Med. I. 212.)
   When an  organ  is  much  atrophied,
there is  not only a diminution of its con-
stituent  molecules, but also a modification
of its physical properties.  It receives less
 blood  than  before; is of a paler colour;
 becomes shrivelled and contracted, or soft
and flaccid,  and  deprived of its natural
elasticity.   Many  of its smaller vascular
 ramifications  seem  indeed to become ob-
 literated, and the whole structure is often
 reduced to  a  mere rudimentary cellular
 tissue,  or  is  entirely annihilated.   In a
case of idiopathic atrophy affecting the
 whole system, which was attended with
 no other symptom than a general wasting
of the body,  Halle  found the lymphatic
 vessels  obliterated,  and  converted into
 small white filaments resembling nerves;
 the glands were desiccated, and of a horny
consistence.   (Mem. de VInstitute. I. 536.
 Lobstein.)
   Treatment.  The fact that atrophy may
 proceed from such a multiplicity of causes,
 many of them very different  in their na-
 ture, sufficiently indicates, that no gene-
 ral system of treatment  can be prescribed,
 which will be suited to all cases.  The
therapeutical indications must be deduced
from the nature  of the offending  cause,
and when that can be ascertained, such
remedies should be prescribed as will be
likely to remove  it  In all cases of par-
tial atrophy, the nutritive  energies of the
affected organ are impaired either directly
or indirectly, and it should be the care of
the practitioner to invigorate them either
by means applied to the part when acces-
sible, bv such as act through the general
system," improving the functions of diges-
tion, chylosis, and hematosis, or by both.
The local remedies must  be  such as will
invite an increased flow of blood into the
                   47*
affected organ, and  thereby increase  its
nutrition.   To fulfil  this  end,  frictions,
stimulating embrocations,  douches, exer-
cise, electricity, galvanism, &c, will  be
indicated.  The internal remedies should
be specially directed to the digestive, and
blood-making  organs, at least in all cases
where the quantity or quality of the nutri-
tive fluids is in fault.   If the defect of nu-
trition depend upon some organic disease,
this should be overcome  if  practicable,
and if there be merely a sluggishness of
the instruments alluded to, their powers
should be  invigorated by a judicious course
of such remedies as will tend to bring the
physiological acts  into full play, and thus
enable them to elaborate an adequate sup-
ply of healthful nutritive fluids. In many
cases, nutrition is not only enfeebled, but
is greatly perverted.  Under such circum-
stances,  alteratives will  be  indicated^-.
and may be advantageously combined with
tonics.  Small and occasional doses of the
mild  mercurial preparations;—of iodine,
especially its  combinations with iron; all
the chalybeate preparations; the vegeta-
ble bitters; mineral waters; baths; exer-
cise ; travelling;  nutritive diet, &c, may
be enumerated as the means upon which
the chief reliance must  be  placed;  the
administration being varied to suit the cir-
cumstances of individual cases.  When
the nervous centres are  in fault, moxas,
and other revellents, applied in the vi-
cinity, may be useful; and similar appli-
cations may be made along the course of
a nerve,  when the atrophy depends upon
a pathological state  of one of those in-
struments.
   Atrophy of the individual organs will
be described in connexion with the other
pathological states to which such organs
are liable;   and  besides  the  treatment
there indicated,  reference may be made
to the article  Marasmus.
   Bibliography.—Andral.  Pricis d'Anatomie
Pathologique.  Paris, 1829.
   Lobstein.  Traiti d'Anatomie Pathologique.
Paris, 1829.
   Bouillaud.  Art Atrophie, in Dictionnaire de
Med. et de Chirurg.  Pratique. III.  Paris, 1829.
   Townsend.  Art Atrophy, in Cyclopedia of
Practical Medicine,  I.   London, 1832.
   Ferrus. Art. Atrophie, in Diet de Medecine.
2d edit. Tome IV.  Paris, 1833,
   Copland. Art. Atrophy, in Dictionary of Prac-
tical Medicine,   Part \,  London, 1833,
                         E, Geddings.

   ATTENUANTS. (From attenuare, to
make thin.)  This term was formerly ap-
plied to designate an imaginary class  of
medicines supposed to possess the property
of increasing the  fluidity of the blood, by 
558                       ATTENUANTS.—AVENA.
diminishing the  size of its molecules, or
by dividing and separating them.  The
latter were  also termed incidentia (q. v.).
It is almost unnecessary to add that there
are no such medicines.  The only means
we possess of rendering the blood more
fluid is by increasing the proportion of its
aqueous constituent (See Diluents, Hu-
moralism, &c.)                  I. H.
  ATTITUDE.  (See Position.)
  AUDITORY.  Appertaining  to hear-
ing.                            I. H.
  AURA.   A Latin word signifying  air
or vapour,  and  employed  by some physi-
cians to designate a subtile emanation or
vapour arising from certain bodies. Thus
the  peculiar emanation given out by the
spermatic fluid, and erroneously regarded
by some as the fecundating principle, was
termed aura seminis, or a. seminalis; and
the  odour  exhaled  from freshly drawn
blood, aura sanguinis.   Van  Helmont
considered the vital principle as a gas or
subtle spirit which he termed aura vitalis.
   The word aura is also used to express
the  sensation of a  kind of vapour which
seems to  pass  from the body or limbs to-
wards the head before an attack of epi-
lepsy or hysteria;  hence  the expressions
aura epileptica and aura hysterica.

   AURANTIUM.   (See Citrus.) '
   AURICLES.    Two  cavities of  the
heart.  (See Heart.)            I. H.
   AURICULA.  Diminutive of auris, an
ear:  the auricle of the ear.  (See Ear.)
                                I. H.
   AURICULAR.   Appertaining to  the
ear, particularly to the external ear. (See
Ear.)
   The little finger is  sometimes termed
the  auricular finger,  because, owing to
its  size, it can be in part introduced into
the external auditory canal.
  This term is also applied to denote what
has reference to the auricles of the heart.
                                I. H.
  AURICULO-VENTRICULAR. Com-
mon  to an auricle and  ventricle of the
heart. The auriculo-ventricular openings
are those which establish the communica-
tion between the auricles and ventricles
of the heart Auriculo-ventricular valves,
the  mitral  and  tricuspid valves.  (See
Heart.)                         I. H.
  AUSCULTATION.   (From  auscul-
tare, to listen.)   This term, originally in-
troduced into medical  language  by Buis-
son, is applied to the methods resorted to
for the purpose of discovering or discrimi-
nating diseases by means of signs recog-
nized  by the sense  of  hearing.   It com-
prises the study of all sounds indicative
of disease, in any part of the body, whe-
ther produced naturally or artificially, and
whether perceived  by the unassisted ear
or by the aid of instruments.  It is one of
the means of exploration,  and in many
diseases a very important one, for deter-
mining, from physical signs, the diagnosis.
It will be most convenient to investigate
all the physical signs of disease under one
head,  which will accordingly be done in
the article Exploration (q. v.).    I. H.
   AUTOMATIC. (From avtouat05, spon-
taneous.)  This term is applied  to those
movements which are made by the pa-
tient without any object, and apparently
without the exercise of volition.  They
differ from convulsive movements, in the
less violence of the muscular contractions
which produce them, and in being easily
arrested.                       I. H.
   AUTOPSY,  avtotyn, Gr.; Autopsia,
Lat  (From avroj,  himself, and o$ij, vi-
sion.)   Attentive examination  by one's
self.  Cadaveric autopsy; tlie dissection
of a dead body for  the purpose of ascer-
taining the  cause of death.  (See Necro-
scopy.)                         I. H.
   A VENA.  (Mat. Med. and Bot.)
   Sex. Syst.  Triandria digynia.   Nat.
Ord.  Grammes.
   Gen. Ch.  Calyx two-valved, two, three,
or many-flowered.   Corol.  exterior valve
lanceolate,  somewhat terete,  furnished
with a dorsal awn.   Awn geniculate and
contorted.  Nuttall.
   A. sativa.  Oats.   Avoine, Fr.; Haber,
Germ.
   Sp. Ch.   Panicled; calyx two-seeded;
seeds smooth, one of them awned.  Lin-
njeus.  The native country of this plant
is not known, but in all probability it ori-
ginally came from  some part of Asia.
Williamson,  on the authority  of  Lord
Anson, says that it was found in the island
of Juan Fernandez: this may be the case,
though  its occurrence both  in that place
and in Sicily, where it also has been dis-
covered in a wild state, can readily be ac-
counted for, without considering  it as in-
digenous.  There can be no doubt that it
was cultivated in Europe long before the
discovery of America, and was  probably
known to the ancients.  There are many
varieties,  differing  in the  colour of the
grain  and in the presence or absence of
the awn.  They are all very hardy plants,
and flourish  best  in cool and damp cli-
mates;  hence the  oats  of England  and
the north of Europe are much heavier and
contain more  farina  than  those of the
United States. This grain, though usually 
AVEN A.—AXILLA.
559
cultivated for horses, forms a very general
article of food  for man  in the northern
counties  of England and Ireland, as well
as in Scotland, Brittany, &c.  The meal
is very nutritive and easy of digestion. It
has been analyzed by Davy and Vogel
with different results: the latter found 59
starch,  4.30 albumen,  8.20 sugar, 2.50
gum, 2  fixed  oil, 24  fibrous  matter, as
well as  a bitter  principle  united  to the
saccharine matter; Davy, in addition, ob-
tained 6 of gluten.   Other chemists have
noticed an aromatic principle in the husk,
having some analogy to vanilla, and which
it is said  can  be extracted by means of
water and alcohol.   Chevallier (Journ.
 Chim. Med. II.  603.) is  of opinion  that
 the fecula of  this grain is closely allied
 to arrow-root, and might be advantageously
 used as a substitute  for it
   The grain, when  deprived of its husk,
 is termed groats (gruau, Fr.), and in this
 state is directed by the British and many
 of the  other  European pharmacopoeias,
 but is not recognized by that of the United
 States;  the only preparation that is offi-
 cinal with us is the meal.
   Oatmeal, when of good quality, has a
 faint smell, and a very  slight  bitter taste.
 It cannot be  formed into raised or fer-
 mented bread, owing  to the  absence of
 gluten,  and hence  is used for food in the
 form of cakes or gruel.   The latter pre-
 paration affords  a light but nutritive ali-
 ment particularly adapted where  a  strict
 antiphlogistic  regimen  is necessary.   As
 generally made, however, from its thick,
 turbid appearance,  it is often extremely
 unpleasant  to patients: as directed to be
 made by Cullen,  the  nutritive portions
 of the meal are obtained  without this dis-
 advantage.  He orders an ounce of meal
 to three  quarts of water, to be placed on
 the fire and stirred till  it boils; the  ebul-
 lition is continued until about a  third of
 the water is evaporated.  It is then strain-
  ed and  suffered  to stand, till, on cooling, a
  sediment is  deposited, when  the  clear
  part is  poured off for use.  When admis-
  sible, sugar and lemon-juice are added to
  improve  the  flavour, but the most usual
  addition is that  of raisins.  Oatmeal gruel
  is slio-htly laxative in  most cases, and m
  some persons even acts with some energy
  on the  bowels.  It is  sometimes  used as
  an enema, and the  meal made into a thick
  paste with hot water  forms a  favourite
  emollient  cataplasm  with  some practi-
  tioners. (See Diet, Regimen, &c.)
          v             R. E.  Griffith.
    AVENS ROOT.   (See Geum.)
 i  AXILLA.   By the term axilla or arm-
pit,  is  generally  understood  the trian-
gular excavation included between the
upper part of the arm, the shoulder, and
the side of the thorax.   In  considering
the surgical  anatomy of the axillary re-
gion, it is  necessary to define its bounda-
ries more accurately, and to include parts
within  it that are not comprised under
the common acceptation of the term arm-
pit applied to this part.
   Art. I.  Surgical Anatomy.   The ax-
illary region, viewed  in  its full extent
is  of a  triangular  shape,   comprising
all that part of the upper portion of the
arm occupied  by  the  attachment of the
pectoraiis major and latissimus dorsi,  and
the corresponding  surface of the thorax.
The  space circumscribed by these limits,
represents a  triangular pyramid, obliquely
inclined,  the apex of which  ranges up-
wards between the clavicle, the scapula,
and the first rib, where it becomes con-
tinuous with the cervical region, while
the base  is downwards,  and is formed by
the skin stretched across the hollow of
 the arm-pit   The other boundaries of the
 region are the pectoraiis major and minor,
 in front;  the  subscapularis,  teres  major,
 and latissimus dorsi, behind;  and the sur-
 face of the  ribs, covered by the serratus
 magnus,  internally.  The superior exter-
 nal boundary, which  is  very narrow, is
 formed by  the  shoulder  joint,  together
 with the adjacent portion of the humerus.
    The height of  the  axillary region is
 greater in the male than in the female;
 but its dimensions vary, according to the
 position  of  the arm.  When the member
 is forcibly elevated from the side, so as to
 put the pectoral muscle upon the stretch,
 the  anterior face  of the  region presents
 nearly a plane surface, having, neverthe-
 less, a slight prominence along its upper
 border, formed by the clavicle (Fig. 1. A.),
 and at its upper and outer portion, a con-
 siderable hollow,  especially  in  lean sub-
 jects,  corresponding to the  external ex-
 tremity of the clavicle, and  the adjacent
  portion of  the  deltoid muscle.  In  this
  situation, a  small triangular space  can be
  distinguished by the touch, bounded inter-
  nally by the coracoid process (Fig. 2. a.),
  superiorly by the acromian, and externally
  by the head of the humerus.  The point
  of the catlin is plunged through the cen-
  tre of this  space, in amputating at the
  shoulder joint, according to one of the
  methods prescribed. (See Shoulder.) The
  base of the  axillary region presents a deep
  excavation, bounded  in  front and behind
  by the folds formed by the pectoraiis ma-
  jor and latissimus dorsi  muscles.  When 
560
AXILLA.  (Surgical Anat.)
the  arm  is but slightly drawn from the
body, this excavation is deep; but when
the member is elevated to a perpendicular
direction,  the cavity is  nearly effaced;
the  head  of the humerus  being forced
downwards, so as to render the surface
somewhat convex by protruding the skin
before it
   The skin occupying the  anterior face
of the  axillary region, presents  nothing
worth noting.  That however, which is
folded into the arm-pit is  remarkable for
its softness,  for the hair which  springs
from its surface, its great number of se-
baceous follicles, and the peculiar odorife-
rous secretion which it pours out.   These
characters  render it very susceptible of
disease, and its follicles, in particular, fre-
quently inflame, and undergo various mor-
bid changes.
   The cellular tissue, with its  adipose
substance,  forms  a stratum, of variable
thickness in different individuals, between
the skin and the deeper-seated parts.  Its
most superficial portion is somewhat loose
and  filamentous, and is traversed by small
vessels, and nervous  filaments from the
cervical plexus.  Near the clavicle, some
of the fibres of the platysma myoides mus-
cle are besides spread out in  its substance.
The  deeper-seated  part  which  reposes
upon the pectoral muscle, is more com-
pact and lamellar, and forms a thin sheet
of fascia  having important relations with
the parts beneath.   Dissecting this fascia
upwards, it is found to be continuous  in
that  direction,  in front  of  the clavicle,
with the superficial cervical fascia; be-
low, it descends upon the abdomen; while
downwards and outwards, along the base
of the  region,  it  is  reflected over the
lower edge of the pectoral muscle, to pass
between it and the pectoraiis minor, on
the one hand, and on the other, to become
lost in the loose cellular tissue of the arm-
pit  Upon the shoulder, it continues  with
the superficial fascia of the arm, being at-
tached in that situation, also, to the acrc-
mian process; and  a little  beneath the
outer end of the clavicle, it penetrates be-
tween the  deltoid and pectoraiis  major
muscles, along the  line  which separates
them,  thus connecting  itself with  the
deeper  layer  presently to be described.
This  superficial fascia adheres intimately
to the  surface of the muscle, especially
along its axillary border,  and  although
possessing no great thickness,  it is suffi-
ciently strong to impede  the progress of
matter to the surface, when that fluid is
formed in the parts beneath.
   The  muscles occupying the anterior
 wall  of the axillary region are, the pec-
 toraiis  major and  minor,  the clavicular
 portion of the deltoid, and the subclavius.
 The first of these (Fig. 1.  C. C.) occupies
 the whole surface, except a small part
 above,  occupied by  the  deltoid.   It  is
 somewhat rhomboidal in shape,—is com-
 posed of fibres which converge as they
 advance outwards  from  their attachment
 to the ribs, sternum, and clavicle, towards
 the outer  margin of the bicipital groove
 of  the humerus; and consists of two por-
 tions,  sufficiently distinct through  their
 whole  extent.  The  first  is  attached  to
 the sternum and true ribs, and is called
 sternal portion: the second is attached  to
 the inner half of the  clavicle; it is deno-
 minated clavicular portion.   They are
 united  by cellular  tissue,  and when the
 arm is extended to  a right  angle with the
 body, a line drawn from the  articulation
 of  the  inner end of the clavicle with the
 sternum,  to  the  tip of the coracoid pro-
 cess,  will indicate the  situation  of the
 union between the two portions of the
 muscle.  This line will also correspond
 nearly to the course of the  axillary artery,
 and an incision following it, will separate
 the clavicular from the sternal portion of
 the muscle, so as  to fall upon tlie vessel
 without dividing any  of the fibres.   It  is
 in this  manner the  incision is made in ap-
 plying  a  ligature to  the axillary artery,
 according to the method proposed by Mar-
 jolin, and recommended by Lisfranc.
  The  inner part of the  pectoraiis major
 reposes, to a limited extent, upon the sur-
 face of the  ribs.  Immediately  beneath
 the middle of the clavicle, it rests upon a
 bed of loose cellular tissue, the deep layer
 of fascia mentioned above,—the  anterior
 thoracic arteries, veins,  and nerves, and
 is here only separated by these structures
 from the axillary artery and vein, and the
 inferior chord  of the  brachial plexus of
 nerves.  Farther outwards, it covers the
 pectoraiis minor, a thin layer of fascia,
 and several small vessels and  nerves run-
 ning between the two muscles. Its outer,
 or inferior margin,  which forms the ante-
 rior boundary of the arm-pit, is in relation
 with  the  mass of cellular  tissue, lymph-
 atic glands,   blood-vessels, and  nerves,
 which  occupy that cavity.  The upper
 portion of the musole is separated  from
 the deltoid  by a  well-defined  furrow,
 which is  occupied  by the  cephalic vein,
as it passes upwards and inwards from the
arm,  to communicate with the  axillary
vein;—also by the  principal branches of
the  thoracico-acromialis artery.  The in-
cision is made along this  furrow in apply- 
AXILLA.  (Surgical Anat.)
561
ing a ligature to the axillary artery ac-
cording to the method recommended  by
Desault and Roux.   The vein and acro-
mial artery would be  necessarily exposed
to injury by such a procedure.
   The attachment of the pectoraiis major
to the clavicle, indicates the  necessity of
confining the arm against the side of the
body in fractures of that bone, in order to
keep the fibres of the muscle relaxed; and
the power it exercises upon the humerus,
tends to displace the fragments when the
shaft of that bone is broken.  The rela-
tions of this muscle with the deep-seated
 cellular tissue of the axilla  give it great
 importance  in extensive  collections of
 matter taking place  beneath its surface.
The pus is  prevented by it from pointing*
at the surface, and is consequently driven
profoundly among the deep-seated parts,
producing  burrowing abscesses, — or  it
travels  through the loose cellular tissue,
towards the arm-pit, and points in that
situation.  Were it not for the slight de-
gree of resistance presented by the meshes
of the  cellular tissue in this direction, af-
fording an easy transit to the matter, the
pus would be much more apt to find its
way through the intercostal muscles, and
be discharged into the cavity of the thorax.
   The  pectoraiis minor (Fig. 1. a.  Fig.
2. b.), covered by the preceding, is of a
triangular figure.   Attached by its inner
extremity to the third, fourth, and fifth,—
flg-l.
        _..,.-,  /. n tw.inni;. nuinr  n Peetoralii-minor.  b, b, Costo-coracoid ligament, e, Axillary vein. A Cephalic
fc a"A^"f, %&£5£EZ&T. %,PA^i"rrScic a'erW. H, Part of the brachial plexus oPnervea. +
or the second, third, and fourth ribs, its
fibres  pass  obliquely  upwards  and out-
wards, to the tip of the coracoid process,
to which they are attached by a short ten-
don  (Fig  2.  a.)  Besides  the pectoraiis
major, and other superficial parts it is co-
vered in front by some  loose  cellular tis-
sue,  and a thin layer of fascia, which
passes between  it  and the  muscle just
mentioned.  It is likewise traversed, upon
this  aspect, by  some  small vessels and
nerves (Fig. 1.  g.), which descend from
above, to be distributed to the pectoraiis
major  and the serratus magnus.   These
vessels consist of some of the branches of
the  thoracica suprema,  which  takes its
origin near the upper margin of the mus-
cle.   Near its outer attachment,  the pec- 
562
AXILLA. (Surgical Anat.)
toralis minor glides in front of the axil-
lary artery, with  its corresponding vein,
and the axillary plexus  of nerves—cross-
ing them nearly at a right angle.  It thus
divides the axillary region into two trian-
gular spaces, through which the principal
vessels and nerves pursue their course.
  The first of these spaces, denominated
by Velpeau, costo-clavicular, is  situated
above the muscle, and  is bounded, supe-
riorly, by the clavicle and the subclavius
muscle; internally, by the surface  of the
ribs, covered by the serratus magnus;  in-
feriorly and externally, by the upper mar-
gin of the pectoraiis minor.  The axillary
artery and vein traverse  it obliquely, co-
vered by a considerable quantity of cellu-
lar tissue,—by the  deep-seated layer of
fascia  presently to be described, together
with  the  aponeurotic expansion called
costo-coracoid ligament (Fig. 1. b.);  and
over these parts, the pectoraiis major.  It
is also in this space that  the cephalic
unites with the axillary  vein (Fig. 1. c,
d.); and towards its lower part, the supe-
rior thoracic  artery generally takes  its
origin.  (Fig. 1. /)  At  this point,  the
axillary artery (Fig. 1. e.)  can be most
fig. 3.
 A, Clavicle.  B, Deltoid, a, Coracoid process,  b, Pectoraiis minor, detached from the coracoid process and reflected, e, Axillary an
tery. d, Thoracic artery, t, Axillary vein. /, Cephalic vein,  g, Axillary plexus of nerves. A, Median nerve,  t, Long thoracic artery.
easily reached, when it becomes neces-
sary to secure it beneath the clavicle.
  The lower triangular space, which may
be  called pectoro-humeral,  is  bounded
above by the lower margin of the pecto-
raiis  minor; outwardly  by the humerus;
and  inferiorly  by the axillary border of
the pectoraiis major.   It is occupied by
the mass of loose  cellular tissue already
mentioned, by numerous lymphatic glands,
and  by the axillary vessels  and  nerves,
which traverse  its upper part, in the vi-
cinity of the shoulder joint  The artery
may be secured in this region;  but as it
is more  intimately  surrounded   by the
plexus of nerves, it cannot be so easily
isolated as above.   This  space, however,
is far more liable  to the development of
inflammation,  abscesses,  tumours,  &c,
and, consequently, to become the seat of
surgical operations, than the space above
the pectoraiis minor.
  The  subclavius  muscle occupies the
lower surface of the clavicle throughout
its whole  extent, and the axillary artery
and  vein  glide  beneath it, covered  by a
tolerably  strong aponeurosis, which  sur-
rounds the muscle,  and passes off from  it
the  coracoid process,  and clavicle, to  be
attached to the ribs.  The small portion
of the deltoid (Fig. 1. B.)  which occupies
the axillary region, presents nothing  wor-
thy of a particular notice, except so far
as regards the furrow between it and the
pectoraiis major already alluded to.
  The deep-sealed fascia mentioned above, 
AXILLA.  (Surgical Anat.)
563
must now be more particularly examined.
When the pectoraiis major  is removed, a
layer of fascia is seen spread out in front
of the  pectoraiis minor, and the axillary
artery  and vein, where  they pass through
the  costo-clavicular  triangular space.   It
is continued outwards with the  capsular
ligament  of the shoulder joint  and the
deep portion of the fascia of the arm;—
upwards,  behind the clavicle,  with the
deep-seated cervical fascia; forwards with
the  superficial fascia covering the pecto-
raiis major, in the manner indicated above;
and backwards, upon the surface  of the
serratus magnus,  and  the  posterior sur-
face of the pectoraiis minor.  From the
inner  margin of the coracoid  process, a
strong lunated aponeurosis (Fig. 1. b, b.),
having its  concave  edge downwards,
ranges inwards, along  the  lower surface
of the clavicle, to the whole extent of
which it is attached, and  becoming ex-
panded at its inner extremity, is inserted
by strong aponeurotic fibres into the car-
tilages of the first, second,  and third ribs.
This is the  costo-coracoid ligament or the
ligamentum bicorne of Caldani.  It fur-
nishes a  strong sheath for the subclavius
muscle, and from its concave edge, a broad
thin sheet  of fascia is  sent oft, which is
spread out upon the whole of the anterior
surface of the pectoraiis minor, and the
space  between that muscle and the sur-
face of the ribs.  Along the edge of the
pectoraiis minor, this fascia  splits into
two layers, one passing behind—the other
in front of  that muscle, so  as to inclose it
in a sheath, these lamina reuniting along
 its  outer edge.  A few  lines below the
 middle of the clavicle, the fascia in ques-
tion presents a crescentic opening, the
 inner   border  of which  is concave out-
 wards, while  the superior  is continuous
 with  the corresponding lunated edge  of
the costo-coracoid  ligament  The outer
boundary of the opening is formed by the
upper edge of the pectoraiis minor.   The
office  of  this aperture  is to transmit the
cephalic vein, which, ascending along the
outer  face of the arm, along the  furrow
between the deltoid and pectoraiis major,
passes through it to unite with the axil-
lary vein,  a little  above  the  pectoraiis
minor.  Above and behind it, is the axil-
lary artery, which  is crossed obliquely in
front by the cephalic vein in this vicinity,
and also by  some small  filaments of nerves
which descend from the axillary  plexus
in front of the artery, to reach the pecto-
ral  and serratus muscles.   The opening
may be aptly compared to that m the fas-
cia  lata of the groin, which is traversed
by tlie saphena vein; and as the relations
of the axillary artery are here  less com-
plex than in other portions  of the region,
this  point should be selected as the most
eligible for the application of  a ligature
to that vessel.  Behind the pectoraiis mi-
nor we generally find the long thoracic
artery (Fig. 2. i.) descending  upon the
surface of the  serratus magnus, upon the
fibres of which it  is chiefly  expended;
and  in its vicinity,  another small branch,
the thoracica alaris, which is distributed to
the glands and other parts in the arm-pit
   The posterior wall of  the axilla  is far
less  important, both to  the pathologist
and  operative  surgeon.  Examining the
structures composing it from before back-
wards, in the  order they  present them-
selves, we find, first, a thin layer of cel-
lular tissue,  or fascia, lining  the whole
extent of this boundary.  From  a line
corresponding to the base of the scapula,
this  fascia is reflected from the serratus
magnus outwards, upon the surface of the
subscapularis, teres major,  and latissimus
dorsi, sending prolongations between the
lacerti of the first of these muscles, which
attach themselves to the  costal  surface  of
the  scapula; and others backwards,  be-
tween the subscapularis and teres major.
This forms a communication between the
cellular tissue  of the axilla, and that  of
the dorsum of the scapula.   Upwards and
outwards this  fascia adheres  intimately
to the  capsule  of  the  shoulder  joint
whence  it continues downwards, on the
long head of the biceps  and the coraco-
brachialis, to lose itself  in the fascia  of
the arm.  Upwards and inwards, it  is lost
in the cellular tissue which ascends be-
hind the clavicle into the cervical region.
   The  muscles entering into the forma-
tion  of the posterior boundary  of the ax-
illa,  are those just  mentioned.   The sub-
scapularis, occupying the  whole  extent
of the concavity of the scapula, has  its
anterior face  looking forwards  and in-
wards, towards the  ribs, from which it is
separated by cellular tissue. Farther out-
wards are the teres major and latissimus
dorsi,  attached by  a common flattened
tendon, twisted upon itself, to  the  inner
border of the bicipital groove  of the hu-
merus,—the  latter  muscle, which  is pos-
terior to the former, advancing  in front of
it where they become  attached to the
bone.  The two together form the  poste-
rior  fold, or wall, of the  arm-pit; and be-
tween them and the outer  margin of the
subscapularis,  there is a considerable
space, occupied by cellular  tissue, through
which the circumflex branch of the sub-
scapular artery is reflected backwards, to
the dorsum of the scapula. 
564                       AXILLA. (Surgical Anat.)
  The inner wall of the axilla is formed
by the walls of the thorax, and of course
takes the convex figure of the ribs.   It is
occupied by  the broad expanded fleshy
portion of  the serratus magnus, which,
taking its  origin from the eight or nine
superior ribs,  winds backward, to be  at-
tached to the whole extent of the base of
the scapula.  It is covered by a thin layer
of fascia, which, as previously remarked,
is reflected outwards from the line of the
posterior attachment of the muscle, upon
the  surface of  the subscapularis.  It is
obvious, from the  manner the  serratus
magnus is inserted into the base of the
scapula, that  the internal and  posterior
walls  of the axilla meet each other at a
very acute angle, and that the disposition
of these parts is such, that there  is  no
natural outlet from the cavity in this situa-
tion.  Matter,  therefore,  cannot travel
backwards in this direction from the ax-
illa, beyond the insertion of the serratus
magnus into  the  base of the scapula,—
that  muscle  presenting  an insuperable
barrier to its further progress.  Nor  is it
likely that the  inner  wall will be  tra-
versed by pus accumulated within the ax-
illa, since,  in addition to the muscle  al-
ready mentioned as occupying its whole
extent it  is still further fortified by the
ribs, intercostal muscles, and other struc-
tures pertaining to the walls of the tho-
rax.   Such an accident has nevertheless
sometimes happened, and a case has been
reported by Lawrence,  in which an ax-
illary  aneurism  found its  way  through
this wall  into the cavity of the chest
The angle formed by the union of the in-
ternal with the  anterior boundary of the
region is  also  acute; but here the  ar-
rangement of the parts  is somewhat dif-
ferent  It sometimes happens, therefore,
when extensive  suppuration takes place
in the axilla, that the pus is forced down-
wards, into  the space between  the  ser-
ratus  and  pectoral muscles; or if that
fluid should be formed  in the latter situa-
tion in the first place, it may travel back-
wards and  upwards, without encountering
any formidable obstacle.
   Descending upon the outer surface of
the serratus magnus, near the lower mar-
gin  of the pectoraiis minor, we  find the
long thoracic artery, and not far removed
from it the external respiratory nerve of
Bell, which, arising  from the posterior
part of the chord formed by the fifth and
sixth cervical nerves, descends behind the
brachial plexus,  and appropriates its fila-
ments to the serratus magnus.  A wound
of this nerve would produce  paralysis of
the muscle to which it is distributed, and
the base of the scapula would, under such
circumstances, be thrown backwards,  or
tilted upwards,  from the ribs, so as to oc-
casion great deformity about the dorsum
of  the  shoulder.   We have  witnessed
several  cases of this  deformity, arising
from  blows and falls  upon the shoulder,
the effect of which was, to overstrain  or
violently contuse the serratus muscle, and
finally give rise to a  temporary paralysis
of its fibres.  Velpeau  also mentions a
case,  in which this condition supervened
upon  a contusion received in the arm-pit.
(Anat. Chirurgicale.   I. 303.)   The  de-
formity  of the  dorsum  of the  shoulder
from  this  cause,  is not generally under-
stood, and we have known much embar-
rassment occasioned  by it.   It  is, how-
ever,  easily recognized.  The individual
has no  power to  draw  the base  of the
scapula forward by the serratus magnus;
but pressure  upon the bone readily  re-
stores it to its proper  place, which it de-
serts, however, as soon as the pressure is
removed.
  The upper and outer boundary is fonned
chiefly by the shoulder joint and all that
portion  of the humerus above the attach-
ment of the pectoraiis  major and latissimus
dorsi.  It is wider within than outwards,
but does not present much interest in a pa-
thological or surgical point of view, except
the articulation and its structures, which
will be considered when we come to  de-
scribe the  region of the shoulder.
   The summit of the axillary region, di-
rected upwards and  inwards, is  open to
give  passage to the  axillary Vessels and
nerves,—they being surrounded by loose
cellular tissue.   The  base is occupied  by
the skin, as already stated, which is folded
upwards, so as to present a deep excava-
tion between the folds formed by the pec-
toraiis in front and  the latissimus dorsi
behind.
   The  parts  comprised  within  these
boundaries must next be described. These
are, the arteries, veins, nerves, lymphatics
and cellular tissue.
   The axillary artery (Fig. 1. e. Fig. 2.
c.) and its branches  have been already
described (see  Arteries); but it will  be
necessary  to  examine  the relations  of
these vessels more particularly, in order
to indicate the manner in which they can
be most easily reached, or avoided, in sur-
gical operations.   This will also serve to
point out  some important indications in
the treatment of wounds implicating the
region under consideration.
   Most anatomists  of the present day de- 
AXILLA.  (Surgical Anat.)
 scribe  the axillary  artery  as  extending
 from the scalenus anticus muscle, to the
 outer border of the latissimus dorsi.  This
 has led to great confusion in speaking of
 operations  upon  this  vessel,  in  conse-
 quence of one portion of it being situated
 above the clavicle, or in the cervical re-
 gion, while  the  other  occupies the axil-
 lary region proper.   To  avoid  this confu-
 sion, and in accordance with  the limits
 which have been prescribed for this latter
 region, we shall restrict the term axillary
 to that  portion of the artery  which ex-
 tends  from  the  second rib to the outer
 edge of the fold of the  arm-pit, formed by
 the latissimus dorsi muscle.
   The  axillary  artery,  thus  defined,
 ranges downwards, outwards, and slightly
 backwards;  and when  the arm hangs by
 the side, describes a  gentle curve, having
 its convexity upwards  and outwards,—its
 concavity downwards  and inwards.  As
 the relations of the  vessel, in its whole
 transit, are exceedingly complex, and im-
 portant to be understood,  it will be useful,
 in accordance with the plan pursued by
 Harrison and Velpeau, to divide it into
 an internal, a middle, and  an external
 portion.
   The first, or internal portion (Fig. 1. e.),
 extends from the second  rib, to the upper
 margin of the pectoraiis minor,  and passes
 obliquely through the  upper part of the
 claviculo-pectoral triangular space, pre-
 viously indicated.  In  this course, it re-
 poses at first upon the outer surface of the
 second  rib and the  corresponding inter-
 costal  muscle; but  it  gradually recedes
 from the side of the thorax, and is sepa-
 rated from the upper portion of the ser-
 ratus magnus by cellular tissue.   When,
 however, the arm is close by the side, it
 reposes to a small extent upon that mus-
 cle.  The axillary vein is in front, but on
 a plane somewhat below the artery. When
 it is fully distended,  however,  the artery
 is nearly concealed by  it.   The cephalic
 vein, gliding in  front of the  pectoraiis
 minor, to  empty itself into the axillary,
 above that muscle, crosses the outer por-
 tion of this division of the artery obliquely
 in front.  At its inner part, the  artery has
 the subclavius muscle and the clavicle in
 front, and further outwards, the lunated
 aponeurotic  expansion,  extending from
 the ribs to the clavicle and coracoid pro-
 cess denominated costo-coracoid ligament
 (Fig. 1.  b.);  the thin layer  of fascia
 which extends downwards from this  ex-
pansion,  and  which  is perforated above
the pectoraiis minor by the cephalic vein,
as previously described;—and the pecto-
  vol. n.          48
                                    565

ralis  major muscle.  Above,  and behind,
the artery is accompanied by the nervous
chord of the  brachial  plexus, which is
formed by  the eighth cervical, and the
first dorsal nerves.  This nerve inclines
more forward in its transit than the ar-
tery,  and is consequently more intimately
connected with it,  at its outer, than at its
inner  portion; and just  before it glides
beneath the pectoraiis minor, it sends a
small  thoracic filament downwards (Fig.
1. g.), between that muscle and the pec-
toraiis major, which crosses the axillary
artery in front, in an oblique direction.
   The second portion of the axillary ar-
tery is concealed by the pectoraiis  minor,
beneath which the vessel glides in its
transit outwards.   Like the preceding, it
has the axillary vein  in front, but more
downward  than in the  region just  de-
scribed;  and the  several  chords  which
form  the axillary plexus,  in separating
from each other, twine upon  the surface
of the vessel  and surround it by a kind
of nervous  sheath.  Having,  besides, the
pectoraiis minor in front and furnishing
in this situation, the  principal thoracic
branches, this  portion of the axillary ar-
tery cannot be so readily secured in a
ligature as the  first  division;  and the
greater facility of reaching the vessel in
the latter  situation,  and of isolating it
from  the surrounding parts, indicate it as
the most eligible point  for the application
of the ligature, when  the operation can-
not be performed upon  the third portion
of the vessel.
   The third and last portion of the axil-
lary artery  (Fig. 2. c.) extends from the
lower edge of the pectoraiis minor to the
outer margin of the latissimus dorsi, when
it takes the name of brachial artery.  In
its course outwards, it reposes posteriorly
upon   the  subscapularis muscle,  which
separates it from the  capsular ligament
of the  shoulder joint, and courses along in
front of the attachments of the teres major
and latissimus dorsi muscles, having the
same  relations with the vein as in the re-
gion just described.  The two radicles of
the median nerve (Fig. 2. h.), where they
approach each other, to unite  in front of
the vessel, have the latter placed between
them—one  root of the nerve being on its
radial, the other on its ulnar aspect.  The
external cutaneous nerve is also on its ra-
dial side, as is likewise the coraco-bra-
chialis muscle.  The internal cutaneous
follows its ulnar side, and the radial and
circumflex nerves gradually recede from
it in  proportion as they incline  back-
wards.  After the artery has passed the 
566                        AXILLA. (Surgical Anat.)
subscapularis muscle, it courses along the
coraco-brachialis, and upon the surface of
the humerus, where,  being superficial, it
can be compressed against the bone.
  A careful consideration of the relations
of the axillary artery, in these three dif-
ferent portions of its  course, will serve to
show, that it cannot be easily tied, except
in the first and third divisions.  In the
first, the principal obstacles are the great
depth of the vessel, and its intimate con-
nexion with  the axillary and  cephalic
veins and  the brachial plexus of nerves.
But these difficulties can be surmounted,
and as the artery seldom furnishes any
branches until it arrives near the edge of
the  pectoraiis minor,  the  chances of suc-
cess are greater than if the ligature were
to be applied in the immediate vicinity of
the  origin  of a collateral branch.  The
second portion  of the artery is also very
deep-seated, and is,  besides, covered by
the  pectoraiis minor, so that to reach it, a
division of" that muscle,  as proposed  by
Roux and  Rust, would be necessary;—
a procedure  which  ought  never  to  be
adopted.   As it furnishes a portion of the
thoracic branches, it is impossible to ap-
ply a ligature  distant enough from  the
origin of those branches,  even  if  the
artery could be reached with ease, to ad-
mit of the formation  of a coagulum of suf-
ficient extent  to  obliterate its calibre.
The third  division of the axillary artery
 can be easily exposed, but it is  so closely
 surrounded  by  the  axillary plexus  of
 nerves, that it cannot be  isolated without
 considerable difficulty, and risk of injuring
 those parts.  The same circumstance, to-
 gether with the great liability of this por-
 tion of the artery to retract deeply in the
 midst of the cellular tissue of the axilla,
 occasions great embarrassment in securing
 the vessel at this point after amputations
 at or near the shoulder joint
   The branches furnished by the axillary
 artery are  of but slight importance in a
 surgical  point of view.  The thoracico-
 acromialis, which comes off near the up-
 per  edge of the pectoraiis minor, mounts
 upwards and outwards, towards the shoul-
 der, and when it runs in the intermuscu-
 lar space  between  the  pectoraiis major
 and deltoid,  is liable to be injured by
 wounds inflicted upon that part and would
 be  divided by the incision recommended
 by  Desault and Roux for the purpose of
 reaching the axillary artery.  The other
 thoracic  branches  generally arise near
 the same point as  the preceding, or be-
 hind the pectoraiis minor.   They  pass
 downwards to the  two  pectoral and tlie
serratus  magnus muscles, and are  sel-
dom  implicated  in surgical  operations.
Nevertheless, it sometimes  happens, in
diseases  of the  mamma,  that  some  of
these  superficial branches  become  so
much  enlarged,  as  to  bleed  profusely
when divided in the extirpation of such
tumours.  The subscapularis comes off on
a level with the outer margin of the sub-
scapularis  muscle,  and may have its de-
scending branch wounded in extirpating
tumours from the axillary cavity.   As it
follows the face of the  muscle, this acci-
dent may in general be avoided; but if it
should be wounded, the hemorrhage can
always be restrained by ligature.  In ap-
plying a ligature to the axillary artery,
on the outer side of the pectoraiis minor,
care  should  be  taken not to secure the
vessel too near the origin of this branch,
lest the free passage of a  considerable
collateral current through it, should wash
away any coagulum that might be formed,
and thus interrupt the process of oblitera-
tion.
   The veins of the axillary region, which
most deserve to be noted are, the axillary,
and the basilic and  cephalic which open
 into it.  All the others are comparatively
small, and although there is frequently a
 considerable plexus of venous branches in
 the axillary cavity, they are not of suffi-
 cient magnitude to render particular pre-
 caution  requisite in the performance  of
 operations on that region.
   The axillary vein (Fig. 1. c.)  is very
 large, and follows nearly the course  of
 the artery of the  same name, being  in
 front, and a little below the plane occu-
 pied by that vessel.  In the upper portion
 of the claviculc-pectoral triangle, where
 the vein passes beneath the clavicle, it is
 more in front of the artery than  at any
 other point  and during expiration, when
 it  is  most distended, frequently conceals
 nearly the  whole of that vessel.   It  is,
 besides,  very  closely  adherent at this
 point, both  to the artery, and the costo-
 clavicular aponeurosis,—an arrangement
 which renders  it difficult to  isolate the
 former, without inflicting injury upon the
 vein. Farther outwards, it inclines some-
 what more  downwards than  the  artery,
 and leaves that  vessel more exposed; but
 in the whole of its transit, its great size,
 and  its close relations with the axillary
 artery,  not  only render it difficult to pass
 an  aneurism needle beneath the latter
 vessel, but expose the vein itself to lace-
 ration or division with the knife.  Such
 an accident besides giving rise to  profuse
 venous  hemorrhage, may prove fetal by 
                           AXILLA.  (Surgical Anat.)

admitting air into  the veins, and should
consequently be carefully avoided.
  The basilic vein does not always ter-
minate in the axillary at the  same point;
but in a  majority of instances this com-
munication  takes place  before the latter
vessel reaches the pectoraiis minor.  This,
however,  is a matter of but little  moment,
as the two veins run  parallel, and are but
slightly removed from each other.  But in
extirpating tumours  from  the  axilla, as
well  as in  cutting down upon the artery
in that region,  both these veins are much
exposed to injury, and great circumspec-
tion is requisite in the dissection, to avoid
implicating them.  Such tumours are, in-
deed,  oftentimes so  closely  adherent to
these veins,  that they have rather to be
separated by the handle, than the edge of
the knife.
   The  cephalic vein (Fig. 1. d.) is more
 superficial,  and  is also greatly exposed to
 injury.   Ascending along the outer por-
 tion  of the  arm, in  a direction slightly
 spiral, when it  reaches  the anterior part
 of the  shoulder, it runs superficially in
 the intermuscular depression between the
 anterior edge of the deltoid, and the pec-
 toraiis major.  It finally glides in front of
 the coracoid process; becomes more  and
 more  profound  as it advances inwards
 from that point, and having reached the
 upper edge of the tendon of the pectoraiis
 minor, crosses the axillary artery obliquely
 in front,  from above downwards and in-
 wards,  and communicates  with  the axil-
 lary vein. (Fig. 2. e.)  It is at  this point
 that the cephalic vein traverses  the open-
 ing formed  by  the costo-clavicular iiga-
 ment and the deep layer of fascia  previ-
 ously described; and as the corresponding
 portion of the axillary artery is  generally
 selected  for the application of the liga-
 ture, it is  sometimes difficult to pass the
 thread  without  injuring the vein.   This
 vein, also,  like the thoracico-acromial ar-
 tery, would be divided in the operation for
securing  the axillary artery proposed by
Desault.
   The nerves of the  axillary region (Fig.
2. g.), after what has been said, do not re-
quire a particular description. They con-
sist of the axillary plexus and its branches.
In the  inner portion of the region, these
nerves are above and behind the  artery,—
only  one of the chords—that formed by
the union of the eighth cervical and the
first  dorsal, being sufficiently near it to
be concerned in any operation performed
upon the vessel.  A little above the mar-
gin of the pectoraiis minor, however, one
or  two small thoracic filaments (Fig. 1.
567
g.) are sent downwards by this nerve,
which descend obliquely outwards, in front
of the artery and vein, to supply the mus-
cles of the anterior  part  of the thorax.
These may be  incautiously divided in at-
tempting to reach the artery, but such an
accident would probably occasion no se-
rious consequences.  Behind the  pecto-
raiis  minor, the  nervous  chords recede
from  each other,  a part of them getting
below the plane of the artery, while the
others remain  above and behind.   Still
further outwards,  the  vessel  is  firmly
bound down by the two roots of the  me-
dian  nerve  (Fig. 2. h.), which meet upon
its surface, and, with the other branches,
surround it with a kind of nervous sheath.
This renders it  the  more difficult to iso-
late this portion of the  axillary artery, to
secure  it  by ligature;  and when these
parts are divided in amputation, the  ves-
sel often retreats  so much, between the
nervous chords which surround it, that  it
cannot be easily found and secured. The
proximity of these nerves to the shoulder
joint exposes them greatly to contusions,
pressure,  and  other  injuries  resulting
from dislocations happening at that arti-
culation.   It is for this reason, that such
accidents are  so  often attended with se-
vere pain, numbness  of the arm and hand,
or even  complete paralysis.    Pressure
upon the veins, from  the same cause, fre-
quently occasions great tumefaction of
the whole member;  and these vessels, as
well as the  artery, may  be  lacerated,
 either by  the  dislocation,  or violent at-
 tempts to reduce it, as will be explained in
a subsequent part of the present article.
   The lymphatics of the  axillary  region
are both numerous and important.  Those
of the  arm, the side  of the thorax, and  a
 portion of those of the neck, converge to-
 wards  this point,  and  form a very intri-
 cate  plexus about the blood-vessels. They
 likewise  present  clusters  of  lymphatic
 ganglia,  disposed  in series,  and  deeply
 imbedded  in the  cellular tissue.  The
 largest cluster of these ganglia reposes
 upon the serratus magnus;  but  there are
 others, placed more  immediately in rela-
 tion  with  the  axillary  artery  and vein,
 both  behind and  in front.   These lymph-
atic ganglia and  vessels are very liable to
take on disease;  and  it is not unusual,
whenever the points whence they take
their origin are  affected with  inflamma-
tion,  suppuration,  and degenerations of
various kinds,  to find these vessels  trans-
mitting the morbid process along their en-
tire length, to  the glands in the axilla—
becoming  themselves  acutely  inflamed, 
563
AXILLA.  (Inflammation.)
thickened, indurated,—filled with pus or
other morbid products, or otherwise trans-
formed from their normal condition.  This
is more  particularly the case in poisoned
wounds  of the fingers  and hand, as those
which are received in the dissection of
dead bodies.  Under such circumstances,
the lymphatics along the whole extent of
the arm  present red, inflamed streaks, ex-
cessively painful to the touch; the glands
of the  axilla become  inflamed and  en-
larged ; the cellular tissue takes on a spe-
cies  of  diffuse  inflammation;  and  the
whole axillary region  is finally involved
in suppuration, or  sloughing.  In  many
pathological conditions of the mamma?,
also, the glands of  the  axilla are remark-
ably prone to take on disease, and in can-
cer  of that organ,  it is well known, that
the  chief obstacle to success from an ope-
ration is, the implication of the  axillary
ganglia  in the morbid affection.
   The  cellular  tissue is  very abundant,
and loose in its meshes.   Having nume-
rous lymphatic vessels and glands embed-
ded in its substance, and  being traversed
by the  blood-vessels  and  nerves,  it not
only fills up the greater part of the  pro-
per  axillary cavity,  but is  prolonged
thence  into the int rstices of the mus-
cles.  From the  axilla,  a considerable
portion  of it passes upwards  behind the
clavicle, to communicate  with  the  cervi-
cal  region.  Collections of matter,  there-
fore, forming in the neck,  often infiltrate
downwards, and point  in the  axilla, and
vice versa.  This tissue is also prolonged,
as previously stated, beneath the pectoral
 muscles, and it often happens, that puru-
 lent deposites become diffused extensively
 in this direction, forming at the same time
 an extensive accumulation in the axillary
 excavation.

   Bibliography.—Velpeau.  Traiti d'Anato-
 mie Chirurgicale.  Tom. I.  Paris, 1825.
   Blandin.  Traiti  d'Anatomie Topographique.
 Paris, 1826.
   Edwards.  A Manual of Surgical Anatomy.
 Translated, with Notes, by William Coulson.
 First American edition, revised and  corrected,
 with additional Notes by James Webster, M. D.
 Philadelphia, 1828.
   Colles.  Treatise on Surgical Anatomy. Se-
 cond edit, with Notes by J. P. Hopkinson,  M. D.
 Philadelphia, 1831.
   Berard.   Art. Aisselle, in Dictionnaire de
 Medecine.  Deuxieme edit. II. 86.  Paris, 1833.
   Lebaudy.  Atlas du Journal des  Connaisances
  Midicales.  PI. xxiii. xxvii. xxxi.   Paris,  1835.
 The wood cuts  illustrative  of this article are
  taken from the two last of these plates.
   Benson.  Art. Axilla, in Cyclopedia  of Ana-
  tomy and Physiology, edited by Robert B. Todd,
  M. D   Part IV.   London, 1835.
  Art. II.  Surgical Pathology.  The
numerous and important structures which
occupy the axillary region, render its sur-
gical pathology a subject of great interest
to the  practitioner.  Under this head may
be included, phlegmonous and erysipela-
tous inflammation of the skin and cellular
tissue; inflammation of the arteries, veins,
and lymphatics; abscess; ulceration;  tu-
mours of various kinds; wounds of the ax-
illa in general, and those implicating the
axillary artery and vein, and the axillary
plexus of nerves; aneurism, and ligature
of the axillary artery; and   aneurismal
varix implicating this vessel and the axil-
lary vein.
  1.  Inflammation  of the Axilla.   The
various tissues composing the axilla  are
liable  to  inflammation, which may take
on either the phlegmonous or erysipela-
tous  character.   Under  each of these
forms, it often presents several modifica-
tions, according to the condition of the in-
dividual, the tissues affected, and the  ex-
tent to which the inflammation is diffused.
  A  furunculoid  form  of inflammation
very often attacks the skin of the axillary
fossa.   It probably  has its origin in the
sebaceous follicles,  and is  excited by fric-
tion, by a neglect  of cleanliness, and other
causes tending to create irritation in the
part.  It generally  presents itself in form
of one or  more  circumscribed  elevated
phlegmons,  hard  to the touch, and  sur-
rounded by an inflamed areola. The pro-
per  remedies are quietude and  cleanli-
ness;— leeches,  fomentations, poultices,
&c,  and  when  matter  forms, a small
puncture to give it a free exit.  In some
instances, when  the constitution is un-
healthy,  the  inflammation assumes  the
character of  carbuncle, — is  extremely
painful, and is attended with  great gene-
 ral  disturbance.  The treatment appro-
 priate for carbuncle in other parts of the
 body should be instituted, and the  tumour
 should be opened early,  to allow of the
 escape of the slough from  its  centre.
 This  may be done  either by the knife or
 caustic.
   Erysipelatous  inflammation very  often
 attacks the skin and cellular tissue of the
 axilla.  When it extends deeply, it is a
 truly formidable disease, sometimes giving
 rise to extensive sloughing of the whole
 of the deep-seated cellular tissue, laying
 the vessels bare,  and burrowing between
 the muscles.  The skin presents  an ery-
 thematous blush; the region of the pec-
 toral  muscle is puffed up, and is doughy
 to the feel; the axillary space is full and 
                               AXILLA.

prominent; and  the  inflammation is  not
unfrequently diffused upon the neck, chest
and extremity.   This form of inflamma-
tion may take place  spontaneously in the
part; but it is frequently induced by in-
juries of the hand, fingers, or fore-arm;
the lymphatics becoming inflamed in their
course  along the  member, transmitting
the disease from  the  seat of injury to the
axillary region, upon which it seizes with
a great degree of intensity.   This is par-
ticularly the  case after  pricks or  other
wounds received  in dissection, the inflam-
mation  excited by which, has a remark-
able tendency to take on the diffused char-
acter, attended with extensive sloughing,
and to involve the whole member in com-
mon with the axilla, or to pass by the for-
mer, and seize upon the latter alone.
   At the onset  of the disease,  leeches
may be applied  freely over  the inflamed
part, followed by  soothing anodyne lotions,
either  tepid or  cold—fomentations, and
the  ordinary  means  of combating erysi-
pelatous inflammation.  When the disease
extends profoundly into the cellular  tis-
sue, free incisions are by far the most im-
portant means,   and should  not be dis-
pensed  with.  They disgorge the blood-
vessels, remove constriction, and if slough-
ing has commenced, give free exit to the
unhealthy matter and sloughs of the cel-
lular tissue, situated beneath  the skin.
(See Erysipelas.)
   2. Abscess of the Axilla.  The charac-
ters of the  structures composing the  ax-
illa, dispose them in a high degree to ab-
scess and its consequences. Independently
of those abscesses  which form in the  ax-
illa  from simple idiopathic  inflammation
of the cellular tissue and lymphatic glands,
there are others, which arise from causes
of a different nature.  Hence it is found,
that  critical  and  pestilential  abscesses
form more frequently in the axilla than in
any other part of the body; and the loose-
ness of the cellular  tissue in this situa-
tion ; its intimate relations with parts pos-
sessing a great susceptibility  to  disease,
together with the freedom of its commu-
nication with  other regions, dispose it in
a peculiar manner, to accumulations of
matter, having its origin  in an affection
of some organ either adjacent or remote.
The neck, the shoulder joint the dorsum
of the  scapula, the arm, and even the ca-
vity of the thorax, may be  the  source of
purulent deposites  in the axilla, the fluid
traversing freely  the meshes of the cellu-
lar tissue in the direction in which it en-
counters the least obstacle, until it points
in the arm-pit. Besides these,  there are
(Abscess.)                           5fJ9

abscesses by congestion,  the sources of
which cannot be recognized. They gene-
rally take place in broken-down habits, in
which the  blood-vessels, or the  tissues
themselves, seem to acquire the property
of forming purulent deposites in the ax-
illa, independently  of  any  manifest in-
flammation  or appreciable  local  lesion,
either in the part or the neighbourhood.
More frequently,  however, the  abscess is
either a  consequence of inflammation of
the cellular tissue or glands of the axilla,
or the matter  finds its way into this re-
gion, from a disease of some of the neigh-
bouring parts.  Pockels mentions a case,
in which it proceeded from caries of the
coracoid process; and a second, in which
the matter  originated in a disease of the
seventh cervical and the first dorsal ver-
tebra,  where the  latter articulates with
the head of the  first rib.  (Encyclopadi-
sches Wbrterbuch. I. 270.)  The accumu-
lation  of pus was  not  preceded by any
evidence of inflammation in the axilla.
Velpeau reports two cases  in which an
abscess formed upon the shoulder, and the
matter traversed the joint, to point  in the
arm-pit. (Diet, de Med.  II. 97.)  In both
cases,  the abscess was a consequence of
amputation;—in the first, of the arm ;—
in the second, of the little finger.  In an-
other instance,  caries of the third rib was
the cause of the disease;  and the  same
author reports two other cases,  in  one of
which the  abscess communicated by an
oblique aperture,  six lines  in diameter,
with cavities in the lungs; while in the
other, the matter proceeded  from  behind
the sternum.   But whatever be the  char-
acter assumed by abscesses  of the axilla,
it is probable, that in a  majority of cases,
the cause of the disease is inflammation
of the lymphatic vessels and glands, ex-
tending to the surrounding cellular tissue,
and exciting extensive suppuration  in its
meshes.
  However this may be, these abscesses
are often more formidable  than is gene-
rally supposed.  The reason of this can
be readily understood, when the nature and
relations of  the parts are considered.  The
great permeability of the cellular tissue,
together with its high degree of extensi-
bility,  is very favourable to the formation
of  large purulent  collections.   Its  con-
tinuity with that of adjacent regions al-
lows the fluid to travel with great facility,
—upwards,  behind the clavicle, into the
cervical  region;  forwards,  beneath the
pectoral muscles; backwards,  upon the
dorsum of the scapula;  downwards,  upon
the arm; and in  some  cases, the  inter. 
570
AXILLA.  (Tumours of.)
costal muscles are destroyed, and the pus
is  either extravasated into the cavity of
the thorax, or a fatal degree of pleuritic
inflammation  is  developed.   Owing to
these conditions,  it frequently  happens,
that while an abscess exists in the axilla,
others are formed in the lower part of the
neck, upon the dorsum  of the scapula, in
some portion of the shoulder, arm, &c,
which,  on a  careful  examination,  are
found to be mere appendages of the one
in the arm-pit, with which they communi-
cate freely.  Velpeau  has reported seve-
ral such instances; and many more might
be collected from the annals of the sci-
ence, in  which the great irritation thus
excited was productive of  fatal conse-
quences.   The long confinement of the
matter, may, besides, give rise  to caries
of the bones; and when the parietes of
the thorax become perforated, or involved
to the extent of exposing the pleura, the
case is generally hopeless,—death being
almost always inevitable. Hildanus men-
tions the case of a child, in which an ab-
scess of the axilla  separated the pleura
from the  ribs,  and attacked  the  lung.
(Observ. Chirurg. Obs. 2. Velpeau.)  A
similar condition was found by Sanson, in
a  young woman who died at Hotel-Dieu,
except  that the pleura was  merely ex-
posed by the destruction of the intercostal
muscles.  (Lond. Med. and Surg. Journ.
V.  668.)  Even when the abscess  does
not find its way into the thorax, the in-
flammation  may  be transmitted to the
pleura, and destroy life by exciting exten-
sive serous  or purulent effusion from the
surface of that membrane.  Two cases of
this kind are mentioned by Velpeau ; and
he  reports another, in which  death was
induced by a large  abscess of the axilla,
opening into the upper part of the thorax.
 (Loc. Cit. 99.)
   The treatment of abscesses of the ax-
 illa may be dismissed in a few words.  It
 consists in opening them early, and freely,
 in order to evacuate the pus, and prevent
the supervention of those formidable con-
 sequences so apt to take place from the
 burrowing of the matter when it is suf-
 fered to  accumulate  in  the deep-seated
 parts. This course we would recommend,
 whether they be simple, pestilential, car-
 buncular,  lymphatic, or congestive.  An
 opposite practice, it is true, has been in-
 culcated  by respectable  authority,  but
 upon very questionable grounds.   Thus,
 it has been  enjoined not to open pestilen-
 tial or critical abscesses ; but to leave the
 matter to be absorbed  or evacuated spon-
 taneously.  The same course has been ad-
vised, in those abscesses which arise from
suppuration taking place in the lymphatic
glands.  Our own experience is unfavour-
able to  such a procedure, and we would
enjoin it as a rule, seldom to be departed
from, that in these,  as well as in other
cases, the matter should be freely evacu-
ated, as soon as fluctuation can be per-
ceived.   It will  save the patient  much
suffering,  hasten  the  cure, and above all,
prevent  the  pus  from  diffusing  itself
amongst the  neighbouring parts.  Some-
times, indeed, it will be necessary to make
a deep  puncture, to  evacuate the fluid,
even when  fluctuation  cannot be  disco-
vered, especially if the other  symptoms
be such as to leave no doubt in regard to
the  existence of a deep-seated abscess.
In  performing the operation,   a  sharp-
pointed  bistoury should be preferred, and
the  puncture made,  if possible,  in  the
most dependent  part.  But  as  the me-
thod of procedure,  as well as the after-
treatment, have been  already indicated in
the  article Abscess, they need not be re-
peated.
  Bibliography. — Pockels.  Art. Achsetteule,
in Encyclopadisches Worterbuch der Medicini-
schen Wissenschaften.  I. 268.  Berlin, 1828.
  Velpeau. Art. AisseUe, in Diet, de Med. II.
96.   Paris, 1833.

  3.  Tumours of the Axilla.   Tumours
possessing various characters form in the
axillary region. Some of these have their
origin  in  the structures occupying the
part  itself, independently of any  remote
affection; others are purely sympathetic,
—the diseased condition being a  conse-
quence of a previous morbid condition of
some other part of  the  body.  Seifert
has,  therefore, very properly divided tu-
mours of the axilla into two classes;—the
idiopathic and symptomatic.  The propri-
ety of this division is more especially in-
dicated in such  tumours as arise from a
diseased state of the  axillary glands; and
as  it rarely  happens that tumours are de-
 veloped primarily in  the  other structures
of  the  arm-pit, we shall consider the sub-
ject in  accordance with this arrangement
   a. Tumours which do  not originate in
 the glands.   It  should be premised, that
 the axilla occasionally becomes the seat
 of idiopathic  tumours, which do not ori-
 ginate  in the lymphatic glands.   These
 are of two kinds;—the first merely con-
 sisting of an infiltration of blood, or air,
 in  the cellular  tissue  of the arm-pit and
 adjacent  structures; — the  second,  of a
 morbid growth either of the soft parts, or
 of the  bones in the vicinity.
   Examples of the first species are often 
AXILLA.  (Tumours of.)
571
 observed after attempts to reduce disloca-
 tions of the shoulder joint, and at  first
 view,  are apt to occasion much alarm, on
 account of the similarity  presented by
 such a condition,  to traumatic aneurism
 from laceration of the axillary  artery.
 The tumefaction  under  such  circum-
 stances, is  owing to the injury sustained
 by the  small veins and arterial ramifica-
 tions of the cellular tissue  of the axilla,
 which  being torn  across, pour out blood,
 and  produce  an  extensive ecchymosis.
 The tumefaction  generally  disappears
 promptly under the influence of rest  and
 cold spirituous  lotions, the extravasated
 blood being absorbed.
   Violence inflicted upon the part, either
 in the manner indicated,  or by- other
 means, not unfrequently gives rise to ex-
 tensive emphysema, by which the whole
 of the  arm, and the adjacent  part of the
 thorax, neck, and  shoulder,  are puffed up
 into  a soft elastic tumour. Velpeau men-
 tions a case, in which this accident  was
 induced by a fracture of the clavicle,  not-
 withstanding the  lung was not wounded.
 In another case which fell  under his ob-
 servation, the axilla became  the seat of
 an emphysematous tumour, merely in  con-
 sequence of the efforts of coughing. (Diet.
 de Med. II. 103.)   When emphysema re-
 sults from  an  injury  sustained by  the
 lung, the  axilla  almost  always partici-
 pates.  Under all these circumstances, the
 disease must be treated on general prin-
 ciples.  (See Emphysema.)
   A case will be  mentioned in a subse-
 quent  part  of this article,  in  which the
 subclavian  artery  was tied, as was  sup-
 posed, for axillary  aneurism; but after the
 death of the patient, it was found that the
 condition which had been supposed to be
 aneurism, was a firm  tumour adhering to
 one  side of the artery,  and implicating the
 brachial plexus.   Mayo has  recorded  a
 case, in which an exostosis of the first rib
 obliterated  the axillary artery, and occa-
 sioned violent pulsations above the clavi-
 cle, simulating aneurism (Lond. Med.  and
 Phys. Journ.  1831.);  and  an individual
 was  admitted at  St. Thomas's Hospital,
 with an axillary  tumour, which  by  part
 of the  surgeons of that  institution  was
 supposed to be  aneurism.  As there  was
 a difference of opinion amongst the con-
 sultants, it was determined to puncture it:
 the operation gave issue to a considerable
 quantity of serous fluid, bringing with it
a number of small  hydatids.  (The Lancet.
VIII. 211.)  Diseases of the shoulder joint,
of the scapula, the outer end of the clavi-
cle, the ribs, &c., may also give rise to tu-
mours extending into the axilla; but such
affections do not require a particular de-
scription.
   It has been  remarked above, that tu-
mours affecting the  glands  of the axilla
may be divided into idiopathic and symp-
tomatic. Each of these orders of tumours
may be subdivided into species, according
to their characters.  Thus, under the head
of idiopathic tumours, we have the in-
flammatory;  the scrofulous;  the cancer-
ous,  including the scirrhous, encephaloid,
and melanotic.  Symptomatic tumours may
arise either from a previous local affection
of some other part;—as  inflammation of
the  fingers,  or paronychia;  dissection-
wounds, or other injuries of the hand,
arm, &c.;  and  morbid affections of the
mamma?;—or  from some constitutional
condition,—as syphilis, scarlatina, typhus
fever, plague, &c.
   b. Idiopathic glandular tumours of the
Axilla.   The  simple  inflammatory en-
largement of the axillary lymphatic glands
does not require a particular or detailed
description.  The parts affected are  hard
and  tense  to the touch; one  or  more of
the  glands become  enlarged and  indu-
rated; the superjacent skin  is occasion-
ally  red and inflamed; and  the  motions
of the  arm  are painful, and performed
with difficulty.   Sometimes the tumour is
small and movable; but occasionally, when
an entire cluster of glands is involved, it
acquires a large size; is hard and lobu-
lated to the feel; and is  so firmly united
with the surrounding parts, as to  maintain
it fixed  or but slightly  movable.  Such
a condition may be  excited by any of the
ordinary causes of inflammation, either
general or local; and the  disease may ter-
minate  in  resolution;  the  inflammation
may become chronic, leaving a permanent
enlargement and induration of the glands;
or it may end in abscess.   The treatment
must be conducted according to the gene-
ral principles already laid down in speak-
ing  of  inflammation and  abscess of the
axilla.
   Scrofulous   tumours of  the  axillary
glands are of more frequent occurrence,
and  are far more  important, as  regards
their consequences.   They are dependent
upon a general scrofulous diathesis, are
developed slowly, without apparent  pre-
ceding  inflammation,  and are generally
unattended with pain, except when they
become so large as  to encroach upon the
surrounding parts, or are themselves at-
tacked by inflammation and suppuration.
In nearly all  cases, they are preceded by
glandular tumours of the same kind in 
572
AXILLA.  (Tumours of.)
some other part of the body, especially in
the neck,  and are besides accompanied
with the ordinary indications ofa general
scrofulous  diathesis.  At  first,  there is
generally a slight enlargement of one or
more of the axillary glands, which are
isolated and movable. But in the progress
of the disease, a whole cluster becomes
involved, and the several enlarged glands
are conglomerated into a solid lobulated
mass,  partially or entirely filling the ax-
illa, compressing the vessels and  nerves,
and producing tumefaction, numbness, and
pain of the whole  limb, with inability to
perform  with it any of the ordinary move-
ments.  Sometimes these tumours are as
large  as the head of a child, or even an
adult,  and  force the arm from the  side to
such a degree that it cannot be brought
down.  Such tumours  are generally so
closely adherent to the  surrounding parts,
that they are firmly fixed,  and are for the
most part immovable.   In some instances,
nevertheless,  even when they have at-
tained a large size,  they can be moved
with considerable freedom.
   The pathological characters of  these
axillary  lymphatic  tumours are extremely
variable, and very often different portions
of the diseased mass are found in very
dissimilar  conditions. Sometimes there is
simply a state of hypertrophy of the tis-
sue of the glands and the surrounding cel-
lular tissue: very often tuberculous mat-
ter is disseminated through the tumour in
considerable quantity;  and this is  found
in all  the intermediate  conditions, be-
tween the state of simple crudity in which
it is deposited,  and  that  of disorganiza-
tion.  In  this latter  state, it is incorpo-
rated  with purulent  matter, and  the tu-
mour itself presents excavations of  varia-
ble  size, filled partly with the fragments
of caseous  matter,  resulting  from the
breaking down of the tuberculous masses,
and pus poured out by  the surrounding
textures.  These cavities are sometimes
small  and  isolated; but as the disease pro-
gresses, they frequently run together, and
the whole axillary region becomes filled
with one immense scrofulous abscess, pos-
sessing  hard and  insensible walls, and
pouring out unhealthy  secretions.   When
such abscesses penetrate deeply amongst
 the vessels and  nerves,  they are apt to
 become  fistulous,  and  cannot  be  easily
 healed.  Under such circumstances, con-
 stitutional irritation and hectic gradually
 undermine the powers  of life, and the in-
dividual is finally destroyed by exhaustion.
   The treatment of scrofulous tumours of
the axilla  is the same as that which  is ap-
propriate in other diseases of an analogous
character.   The remedies  for  scrofula,
both local and general, must be employed,
and  varied to suit the circumstances of
the case. Sulphuret of antimony, in small
doses; mild mercurials, administered with
a view to the alterative effects  of the re-
medy ; muriate  of baryta; acorn coffee;
the  preparations of iodine;  animal  char-
coal, recommended by Gumpert (Rust's
Magazin  der  gesammten  Heilkunde.
XXV. 121.); cicuta, and other agents
employed in the treatment  of scrofula,
may be  resorted to here.  The dietetic
precepts,  recommended  in  that disease,
will also be  applicable to this, and should
be  carefully  observed.  The local  treat-
ment must consist for the most part  of lo-
tions,  ointments, baths,  plasters,  to be
preceded, when  inflammation exists, by  a
few leeches.   The  salt poultice has been
much  recommended  for the dispersion of
such tumours; as have also the ointments
of mercury,  either simple, or combined
with camphor,  cicuta,  and  other sub-
stances possessing stimulating or narcotic
properties.   By far  the most valuable
agents that  can be employed under such
circumstances  are,  the  preparations of
iodine, employed in  form of  ointment.
For the manner of using them, and an ac-
count of the different preparations,  see
Iodine, and Scrofula. When suppuration
takes place, and the tumour becomes fistu-
lous, it has been recommended  to transfix
the entire mass  with  a seton. This course
may be expedient in some cases;  but  it
will generally be preferable to lay open
the sinuses  freely, and  dress the  cavity
of the abscess  from  the  bottom, putting
the patient at the same time upon a gene-
rous diet, and giving him the  advantage
of  pure  country air.  In this  condition,
bandages, so adjusted as to maintain equa-
ble  and  gentle  pressure, will also be use-
ful, and should not be neglected. Should
these  means fail, and the tumour become
so large as to interfere seriously with the
motions of the arm, it may be removed by
an operation.  This  expedient should not
be  resorted  to  when the glands of the
neck, and other parts of the body, are ex-
tensively involved,  inasmuch  as such  a
condition shows, that the system is  too far
implicated, to admit  of much benefit be-
ing realized  from the removal of the axil-
lary tumour.  Under more favourable cir-
cumstances,  the diseased mass may some-
times be dissected out with success, and
this should  not be neglected,  when all
other remedies have failed.  Several cases
have been reported by Velpeau, in which 
AXILLA.  (Wounds of.)
573
he practised this operation with complete
success.   (Diet,  de Med.  II. 106., and
Journal Hebdomadaire.  No. 51.  p. 276.
1835.)  The  same practice  also proved
highly satisfactory in the hands of Goy-
rand. (Lancette Francaise. II. 257. 1829.)
  The  steps  of the 'operation must  of
course vary according to the size and situ-
ation of the  tumour.  When it  can  be
reached  from  the arm-pit  the  incision
should be made at that point; but when
it is larger, and extends upwards  beneath
the pectoral muscle, it should be dissected
out  beneath the  clavicle,  by extending
the  incisions  through the skin and pecto-
raiis major,—dividing also  the pectoraiis
minor, should it be necessary  to do so.
   Scirrhous, enccphaloid, and cancerous
tumours,  seldom  form  in the axilla, ex-
cept when they are sympathetic of a simi-
lar  degeneration  of  the  mamma?, or  of
some part of the arm, or shoulder.   To
this rule,  however, there  are some excep-
tions. Velpeau mentions a case, in which
fungus haematodes originated  in this  situ-
ation.  He states that two others had  been
mentioned to him by Ollivier, and that
there is one of the same  kind recorded in
the  Theses of Paris.  (Op. Cit.  p. 103.)
The resources of art generally avail but
little against  tumours of this class; the
event being almost invariably fatal,  even
though the disease be extirpated with the
greatest care.  If the disease be observed
at an early  period, and be sufficiently iso-
lated from the surrounding parts, the ope-
ration may be justifiable, even  though
there be but little hope of success.
  c. Symptomatic glandular tumours of
the Axilla.  The causes of these tumours,
already indicated, convey  a sufficiently
accurate  idea of their  nature.   As the
conditions which  give rise to them vary,
it must be apparent that their characters
must  also  be  exceedingly  dissimilar.
Those which  depend  upon  a venereal
taint, possess all  the properties of other
glandular swellings produced by  that vi-
rus, and are, like them,  liable to suppu-
rate and terminate in troublesome sores.
Paronychia, dissection-wounds, and other
diseases  and accidents affecting the hand
and  arm, likewise  give rise to swellings
of the axillary glands, which are prone to
suppurate.  Sometimes, indeed, these ac-
cidents, especially dissection-wounds, are
followed  by inflammation  and swelling
of the  axillary  glands,   attended   with
extensive sloughing  of the surrounding
parts. (See  Wounds.)  Critical swellings
of the  axilla from  scarlatina,   typhus,
small-pox, &c, and  the pestilential tu-
mours, which form in plague, need not be
described in the present article, as they
can be  more appropriately considered in
connexion with the diseases to which they
belong.   It will be  sufficient to remark,
that they generally terminate in abscess,
and  very often by  extensive  gangrene,
and  sloughing.   Enlargement  of  these
glands from diseases of the mamma? are
of frequent occurrence.  The enlargement
may be either a result  of simple inflam-
mation,  transmitted to  the glands from
the mammae, or it may be of a scirrhous
or cancerous character, the  morbid pro-
cess being extended to  the  axilla by the
lymphatic   vessels  which communicate
with the mammary gland. (See Mamma,
Diseases of.)
  Bibliography. — Benedict.   Bemerkungen
uber die Krankheiten der Brust, und Achseldru-
sen.  Breslau, 1825.  4to.
  Siefert.  Art. Achseldrusengeschwulst, in En-
cyclopadisches Wcirterbuch der Med. Wissen-
schaft.  I. 270.  Berlin, 1828.
  Rust.   Art. Achseldrusengeschwulst, in Hand-
buch der Chirurgie.  I. 255.  Berlin, 1830.
  Velpeau. Art. Aisselle, in Diet, de Medecine.
Nouv. ed.  II. 103. Paris, 1833.
  Dufresse.  De  Vengorgement  des ganglions
lymphatiques du creux de I'aisselle; Clinique de
M. Velpeau ; Journal Hebdom. des Progres des
Sc. Medicales. No. 51.  p. 276.  Paris, 1835.
  4.  Wounds of the Axilla.   Wounds of
the axilla, not implicating the large ves-
sels and  nerves, although not usually very
formidable,  nevertheless  present several
points of interest  to the surgeon.   The
peculiar laxity of the skin  and cellular
tissue of the axillary fossa, together with
the mobility and the peculiar configura-
tion  and relations of the parts, render it
difficult  to  maintain the edges of such
wounds in a state of coaptation.  In what-
ever position the member be  placed, the
lips  of  the  wound  are  apt  to be  either
drawn asunder, or folded upon each other
in such  a manner,  as  to interfere with
union by the first intention.   Besides, the
small vessels which are wounded,  gene-
rally bleed sufficiently to inject  the loose
cellular tissue with blood to a considerable
extent; and in some cases, this takes place
to such a degree, as to prove a source  of
great irritation, or even to give rise  to ex-
tensive suppuration—a condition which is
very apt to take place  in this situation
under  all  circumstances.   We do  not
think,  however,  that such wounds will
often give rise to the species of traumatic
emphysema, mentioned by Velpeau (Diet.
de Med.  2d ed. II. 103.), by the mere in-
filtration of air between  the edges of the
wound.
  a.   Wounds  of  the   axillary artery. 
574                         AXILLA.  (Wounds of.)
Wounds of this artery may be either in-
cised, punctured, or lacerated.  The two
former varieties, inflicted by sharp instru-
ments, generally bleed profusely; but the
latter is very often unattended with he-
morrhage, although the vessel be entirely
severed, or the arm be torn from the body
at the same time.
   Incised  and punctured wounds  may
reach  the axillary artery  through  the
space  between the pectoraiis  major and
the  latissimus dorsi,  or they may pene-
trate the pectoraiis major at  some point
below the  clavicle, corresponding to the
course  of the artery,  and  thus divide
its tunics.  The  immediate  phenomena
attendant upon such an accident, will of
course vary according to the extent of the
external opening,  and the depth and di-
rection of the wound  through the  parts
surrounding the vessel.   When the aper-
ture is small, the direction  of the wound
very oblique,  or its depth great,  there  is
often very little  blood  discharged exter-
nally after the first gush; but that fluid,
driven into the meshes of the  cellular tis-
sue, and diffused  into the spaces between
the  muscles, accumulates there, until the
whole axillary region becomes enormously
distended by a mass of coagulum, and the
bleeding is either arrested by  syncope,  or
the coagulum obstructs the  orifice of the
wounded artery, and  thus commands the
hemorrhage.  Under such circumstances,
the pectoraiis major is protruded forwards,
so as  to be  rendered  prominent beneath
the  clavicle; the  axillary  hollow is ef-
faced  by the distension of the skin and
cellular tissue; the scapula is tilted up-
wards from the side of the chest; and the
shoulder, with the outer end of the clavi-
cle, is often considerably elevated. Should
tlie  external opening be large enough to
allow the blood to  flow away, or the wound
of the artery such, as to preclude the pos-
sibility of the hemorrhage being arrested
either  by syncope or coagulum,  death
soon ensues from the loss of the vital fluid,
unless it be arrested by the assistance  of
art.   Even when an arrest of  hemorrhage
does take place by either of the processes
indicated, it is generally only of temporary
duration — the bleeding  being  renewed
from time to time, until stilled by death;
or after  being commanded  for  several
days, it breaks out afresh, after the de-
velopment of suppuration in  the wound,
and the consequent displacement or disso-
lution  of the  coagula  which served  to
command  it  for  the  time.   Sometimes,
nevertheless, when the wound of the ves-
sel  is favourable  to the development  of
those changes by which  hemorrhage is
spontaneously arrested, the bleeding is not
renewed in this manner, but the coats of
the artery, together with the adjacent tis-
sues, undergo such  modifications,  that
while they serve to restrain the hemor-
rhage, they give rise  to a false consecu-
tive aneurism.
  In the  article  Arteries, it was  stated,
that wounds  only implicating a small ex-
tent of a vessel, are  capable of being
closed by the spontaneous  efforts of na-
ture, so as to leave its calibre entire.  Al-
though such a result cannot often  be ex-
pected in wounds of so large an artery as
the axillary,  there are some cases record-
ed,  which render it probable that  such a
termination  may sometimes  be realized.
Certain it is,  the artery may be  severed in
this situation, and  yet the wound  heal
without the  assistance  of art or the de-
velopment of a false  consecutive  aneu-
rism.  Van Swieten reports the case of
a peasant, who had  the  axillary  artery
wounded  by a knife.   The hemorrhage
was so alarming that the individual was
left for dead.  The police officers, on pro-
ceeding the  next  day to  examine the
wound, finding  some warmth  about the
region of the thorax, were induced to de-
fer the investigation.  By  proper  atten-
tion, the powers of life were gradually re-
stored,  and  the  man  recovered without
further inconvenience.  (Van Swieten.
Comment, in Boerh. Aph.  I.  235.   Be-
rard. Diet,  de Med. IV. 486.) A  more
satisfactory case  is reported by Guthrie.
(On the diseases and injuries of arteries.
p. 308.)   A  master  tailor  of the  British
army, was wounded in the right arm by a
pike, at the  assault on Badajos. He bled
like a pig, according to his own account,
and became  faint; but  as his wound was
thought to be trifling on his arrival at tlie
spot indicated for surgical  assistance, no
attention was paid to him,  notwithstand-
ing he fainted. He experienced but slight
inconvenience on the next day; but it was
afterwards found, that the arm was cold
and powerless; that the wound, about one
third of an inch in length, and  a little be-
low the edge of the pectoral muscle, was
directly over the seat of the artery; that
the arm was numb  and pulseless at the
wrist, although the  pulse  could  be dis-
tinctly felt upon  the  artery as low as the
seat of injury, which was  harder and a
little more  swollen  than  natural.  The
temperature of the arm gradually  return-
ed, and after the expiration of something
more than a  fortnight, the pulse could be
felt a little  below the wound,  and after- 
AXILLA.  (Wounds of.)
575
wards along the edge  of the biceps mus-
cle ;  but a good deal of unpleasant numb-
ness remained in the fingers and thumb.
   Far  more frequently it happens, when
the hemorrhage ceases spontaneously, that
after  the expiration of a short time,  a
pulsating tumour is observed in the situa-
tion of the  wound — a false consecutive
aneurism  being the consequence of the
inadequate restoration of the injured parts.
Such an  aneurism  may be  either  dif-
fused or circumscribed;  but if small at
first it generally expands with great ra-
pidity, and soon becomes so large as to fill
the whole axillary cavity; or if it be seat-
ed above the pectoraiis minor, it becomes
diffused extensively under that muscle and
the pectoraiis major.  A very interesting
 example of this kind  is reported by Lar-
 rey,  in which amputation became  neces-
 sary.  An officer was wounded in  single
 combat with the point of a sword, which
 penetrated the axilla near the head of the
 humerus, and not only punctured the  ar-
 tery, but partially  divided the adjacent
 portion of the biceps muscle.  The with-
 drawal of the instrument was followed by
 profuse hemorrhage, which, however, was
 easily arrested by the compress and ban-
 dage ; and under the use of a uniting ban-
 dage the wound healed by the first inten-
 tion.  Subsequently, however, a pulsating
 tumour made its appearance at the situa-
 tion  of the cicatrix, which rapidly  in-
 creased in  size, until it filled the whole
 axilla—being as large as the two  hands.
 In consultation,  it was decided that am-
 putation should  be resorted  to, and the
 limb was  successfully removed  at the
 shoulder  joint (Larrey.  Clinique Chi-
 rurgicale.  III. 132.  Paris, 1830.)  An-
 other case,  in which amputation was ren-
 dered  necessary  by a false  consecutive
 aneurism of  this artery,  is reported by
 Debaig. (Berard. Diet, de Medecine. IV.
 486.)   To  these  may be added the cases
 observed by Desault, Sabatier,  Cham-
 berlain,  Hodgson,   and   Langenbeck,
 which  we  shall have occasion to notice
 under the head of  aneurism of the axil-
 lary artery.  In all these instances, false
 consecutive aneurism  supervened upon  a
 wound inflicted upon this vessel, and ren-
 dered  the  ligature  of  the  artery ne-
 cessary.
   It sometimes  happens that the  wound
 implicates  both  the artery and the vein.
 Under such circumstances, if the hemor-
 rhage  should  cease spontaneously, or be
 arrested by pressure, the artery projects a
 portion of  its blood into the vein through
the orifice of communication,  thus occa-
sioning  a preternatural dilatation of  that
vessel, presenting all the characters  of a
varicose aneurism (q. v.).
  It will sometimes be difficult to form a
correct diagnosis in wounds of the axilla.
A wound of the artery may be easily dis-
tinguished from one implicating the vein,
by the colour of the blood, and the man-
ner in which it escapes from  the wound.
If the artery be wounded, the blood will
be  vermilion,  and  thrown  out in  jets;
whereas if the vein alone be  implicated,
dark  venous blood  will flow away,  in
nearly an even stream.  The greatest dif-
ficulty will be  experienced,  when the he-
morrhage  is arterial,  in distinguishing
whether  the  axillary  artery  itself be
wounded, or some  important  branch fur-
nished  either  by  that  vessel,  or  some
other.  A profuse hemorrhage may take
place from one of the thoracic arteries—
the  subscapular, circumflex, or  even one
of the intercostals,  and awaken a suspi-
cion  that the main artery itself has been
wounded.   In most cases,   however,  a
wound  of the  axillary artery will be at-
tended  with  a complete suspension of the
pulse at the  wrist, and great coldness and
numbness of the member.   But although
these phenomena may be regarded as af-
fording strong  presumption of the nature
of the injury, they cannot be deemed con-
clusive ; since the  cessation of the pulse
may take place in injuries implicating one
of the  branches, either from  syncope re-
sulting from the loss of blood, or in con-
sequence of such an accumulation of ex-
travasated blood about the main artery, as
to intercept  the circulation through it by
pressure.  The coldness and numbness, it
will readily be conceived, may be induced
in the same manner. If,  however, these
characters be taken in connexion with the
situation and direction of the wound, and
all  the  other  collateral circumstances,
most  of the  difficulties  may be  sur-
mounted.
   Lacerated wounds of the  axillary ar-
tery are  far more  frequent than such as
are inflicted by cutting instruments. Their
most common  cause is gun-shot or other
projectiles;  but they are sometimes occa-
sioned by individuals falling from a height,
and lighting with  the  axilla  upon some
obtuse projecting body.   The  axillary ar-
 tery has also  been several  times  torn
across by the  force employed to reduce
dislocations of the shoulder of long stand-
ing ; but the most formidable injuries  of
this vessel are those which  happen when 
576                         AXILLA.  (Wounds of.)
the entire member is  torn from the body
by machinery,  some  examples of which
have been recorded.
  The same phenomena which have been
described, when treating of wounded ar-
teries in a preceding article, are observed
when the axillary artery is injured.   In
this, as  in other vessels, the effect of the
wound  will sometimes vary considerably,
according as  the artery is  partially or
completely severed.   It  is  well known,
that lacerated wounds, even of large ar-
teries,  are not much disposed  to  bleed
profusely;  and several cases  have been
reported,  in  which  no  hemorrhage  en-
sued, notwithstanding that the  axillary ar-
tery was torn entirely across. When, how-
ever, a musket-ball  implicates a portion
only of the diameter  of the  vessel,  the
bleeding is apt  to be profuse, and to con-
tinue, unless arrested by art until life is
destroyed.   At the battle  of Talavera,
Guthrie  was  induced to  examine  a
French soldier, who had just expired from
loss of blood occasioned by a musket-ball,
which passed through the pectoral mus-
cle in the direction of  the axillary artery,
making its exit behind.  On dividing the
muscle, he found the artery cut more than
half across—the  portion which remained
unsevered, preventing the contraction and
retraction of the extremities  of the ves-
sels, which were necessary to arrest the
hemorrhage.  (Op. Cit. p. 305.)   In some
cases, however, the vessel, though struck
by the ball, is not torn; its elasticity pro-
tecting it against the laceration which
would otherwise be inflicted.   The con-
sequence of such an injury may be  either
inflammation and consequent  obliteration
of the vessel, or the development of con-
secutive hemorrhage by sloughing of its
tunics.  The author just quoted has given
examples of both of these terminations, in
wounds of the axillary  artery.   Captain
Gibbons was wounded by  a musket-ball,
which passed immediately below the  cla-
vicle, and out  behind, so directly in the
situation of the axillary artery, that it was
supposed  it must be injured.   Great  in-
flammation followed in the chest, and his
life was saved with difficulty.  He finally
died of phthisis, and it was found that the
artery was obliterated at the point where
the ball had passed by its side. (Guthrie.
 On  wounds and injuries of the arteries.
p. 303.)  No alarming degree of hemor-
rhage is mentioned as having  occurred at
the  time, indicative  of a destruction of
the coats of the  artery; but in the case
of a  French prisoner, who was wounded
at the  battle of Salamanca, it was found
necessary to apply a ligature to an axil-
lary artery several days after the receipt
of the  injury, in consequence of slough-
ing of the coats of the vessel. (Op. Cit.
304.)
  Although but few cases have been  re-
ported, of laceration of the axillary artery
by attempts made to reduce dislocations
of the head of the humerus, there  is rea-
son to suspect that  many such accidents
have occurred  in practice.  It happened
in two instances in the hands of Profes-
sor Gibson of Philadelphia, both of which
were fatal.  (Philada. Journ. of the Med.
and Phys.  Sciences.  VII. 81.  1823; and
American  Journ. of Med. Sciences.  II.
136. 1828.) It is stated by Charles Bell,
that in employing the ambe, in the New-
Castle  infirmary, both the axillary artery
and the muscles were torn, rendering im-
mediate amputation necessary (Operative
Surgery. Amer. edit. II. 176.); and Pro-
fessor Gibson refers to another instance
of laceration of this  artery, by  attempts
to reduce a dislocation of the shoulder, on
the authority of Pelletan. (Clinique Chi-
rurgicale.  II. 95.)   A case of the same
kind is also reported  by Flaubert, which
occurred in  the Hotel-Dieu  of Rouen.
The artery was found torn entirely across,
a little above the origin of the subscapular
branch.  (Repertoire  General d'Anat. et
de Physiologie, &c.  III. 55. Paris, 1827.)
  In some  of these instances, nothing was
observed at the time,  to awaken a suspi-
cion of the accident that had happened.
In  Flaubert's  case, however, the coun-
ter-extending bandage was scarcely  re-
moved,  before  an enormous tumefaction
appeared beneath the  pectoral muscle;
the countenance became pale; the lips
livid, and the eyes death-like: the pulse
was also extinct at the wrist.  The swell-
ing was, however, attributed to an em-
physematous condition of the cellular tis-
sue of the axilla; and as the nature of the
injury was not ascertained until the next
day, when the circumstances were such
as to forbid the application of a ligature
to the subclavian artery, the mischief con-
tinued until the limb became gangrenous.
In  the cases reported by Professor Gib-
son, the  phenomena were developed less
promptly;  but as they had made sufficient
progress in the last, by the second day, to
indicate  the  character of the injury sus-
tained, a ligature was applied to the sub-
clavian artery on the third day. Notwith-
standing this precaution, the case went on
to a fatal termination.
  As the  efforts at  reduction are often
productive of  great tumefaction  of the 
AXILLA.  {Wounds of)
577
parts, and  not unfrequently,  of an em-
physematous, or bloody,  distension of the
cellular tissue of the  axilla and beneath
the pectoral muscle, it will be difficult  to
distinguish  those cases  in which the ar-
tery is torn. Desault reports a case well
calculated  to  point out the difficulty of
diagnosis under  such circumstances.  It
was a dislocation of a month and a half
standing, which,  after  some difficulty, was
reduced; but  immediately  afterwards,  a
tumour rose suddenly under the pectoraiis
major; propagated itself towards the arm-
pit and occupied immediately  its whole
extent  All the assistants, astonished  at
the phenomenon, knew not to what cir-
cumstance to attribute it  Desault him-
self, a little embarrassed, thought first of
an aneurism suddenly produced by the vio-
lence of the extension.  The pulse of the
patient being scarcely perceptible in the
side affected,  and syncope which super-
vened, appeared at first to favour this sus-
picion; but immediately, the absence of
fluctuation, of pulsation, and of a change
in the colour  of the skin,—the return of
the pulse, the circumscription of the tu-
mour, its resistance, and the sound caused
by striking on it produced a belief, that it
was owing, not to an effusion of blood, but
to a disengagement of air that had been
confined in the cells of the now lacerated
cellular membrane.   Under  the use  of
proper applications to the  parts, the tu-
mour  was   entirely reduced.  (Desault.
On Fractures and Dislocations.   Trans-
lated by Charles Caldwell,  p.  149.
Philadelphia, 1817.)
   Laceration  of the axillary artery, from
the  cause  mentioned, is generally asso-
ciated with so much injury of the sur-
rounding parts,  that  little hope  of reco-
very from such an accident can be enter-
tained.  Not only is the vessel  torn, but
likewise the muscles,  cellular tissue, and
sometimes  also the nerves.  The blood  is,
besides, driven  deeply  into the  cellular
tissue, and  if the individual should not  be
immediately destroyed, violent  inflamma-
tion will be apt  to ensue, involving the
whole member in gangrene.  The princi-
pal circumstances creating a liability  to
such an accident are,  a diseased state  of
the artery,  and the contraction of preter-
natural adhesions between it  and the dis-
located head of the bone.  Similar  con-
nexions are sometimes formed between
the head of the humerus and the chords
of the brachial plexus of nerves; and at-
tempts at reduction, under such  circum-
stances, may  tear up the  roots of these
nerves from their  connexions with the
  vol. n.          49
spinal marrow, as happened in some cases
reported by Flaubert in the memoir al-
ready quoted.
  The appalling cases, in which the axil-
lary artery is severed by the entire  arm
being torn from the body, are fortunately
of rare occurrence.  The first instance of
this kind of which we  have any know-
ledge,  is  one  reported by Cheselden.
(Philosoph.  Transact,  and Cheselden's
Anatomy, p. 321. Plate xxxviii. London,
1756.)  The  subject of the case was a
miller, who got his arm caught  in a rope,
the other end of which was fastened to
the cogs ofa mill.  The vessels bled very
little, and the arteries and nerves  were
drawn out of the arm.  The surgeon who
was first called placed  them within the
wound, which was dressed superficially,
and the next day the patient was placed
under the care of Mr. Ferne, of St. Tho-
mas's  Hospital,  where  he  Anally  reco-
vered without suffering any severe symp-
toms.   Two other cases of  the same kind
are reported, both of which happened in
children.  The  first is recorded by  La
Motte, in  his Traite des accouchemens;
the second by Carmichael, in the Edinb.
Medical Commentaries, Vol. V.  In  La
Motte's case, the bleeding was so slight
that it was stopped with a little lint; and
the same absence of hemorrhage was ob-
served in the other case: both terminated
favourably;—the first in a short time,—
the second  in two months. (Art. Wounds,
in Cooper's Surg. Diet.)   The following
case, reported by Sir Charles Bell ( The
Principles of  Surgery, &c.   By  John
Bell,  with  Commentaries, by Charles
Bell.  I. 369. London, 1826.), is so impor-
tant as to merit a more detailed report.
A girl had her arm torn off near the
shoulder, by  machinery.  There was no
bleeding, nor could the trunk of the ar-
tery be seen.  As the  arm had been al-
most fairly amputated by the  machine, it
was unnecessary to do  more than make
the edges of the wound even, and bring
them  together.   As the axillary artery
had not been  tied, the patient was  care-
fully  watched.   In the course of a few
days hemorrhage came on, and Mr. Smith,
of the Leeds Hospital, very properly tied
the artery  just below the clavicle.  The
bleeding  from  the  stump immediately
stopped, and everything went on well for
several days; the stump  became  clean.
and was granulating, when a second vio-
lent hemorrhage took place from it.   Mr.
Smith, on reaching the hospital after the
patient had lost a considerable quantity
of blood, immediately tore open the stump, 
578
AXILLA.  (Wounds of.)
which was already partly united, and saw
the blood issuing  from the main  artery.
The vessel was  secured, but  the  patient
sunk next day, and on dissection, it was
found  that  the  artery was obliterated
where it had been tied, and that the blood
had  passed  round by  the  supra-scapular
branch  of the inferior  thyroid,  from  the
portion  of the subclavian artery above the
ligature, into the part below.
   The first care of the surgeon, on being
called to a case of wound of the axillary
artery,  should be to command the  flow of
blood,  by compression of the subclavian
where  it passes over  the  first rib.  The
manner of doing this has been described al-
ready, when treating of wounds of the ar-
teries. (II. 438.)  Having confided this duty
to a competent assistant, he should, with-
out delay, if the condition  of the patient
will admit, proceed to search for the  end
of the bleeding vessel, and secure it in a
ligature.  The  ease  or difficulty  with
which this operation can be accomplished,
will depend upon the portion of the artery
that has been wounded, and the degree to
which the surrounding parts have  become
injected with  blood.   When the outer
third of the vessel  is injured,  it  can be
generally drawn  out  and tied without
great trouble or embarrassment;  the ex-
ternal wound, if small, being previously
dilated to the proper extent, so  as to ex-
pose the jet of blood  thrown  out  by
the end of the artery.   Sometimes, how-
ever, the parts  are so filled with coagu-
lated blood,  as  to occasion considerable
difficulty, and the artery is so closely sur-
rounded  by  the  corresponding nervous
chords, as to  render its separation rather
troublesome. If, however, the wound of the
integuments be  sufficiently Jarge,  and the
coagulated  blood  be carefully turned out
from the parts in  which it  is lodged, the
operation may be accomplished with con-
siderable facility.   Great care will be ne-
cessary, however, in passing the ligature,
not to include the nerves, and to avoid in-
juring the axillary vein.  In some cases,
a ligature to  the  upper end of the vessel
will be adequate  to command the hemor-
rhage ; but as there is  a great liability to
hemorrhage from  the other end of the ar-
tery, in consequence of the passage of the
blood  round through  the collateral ves-
sels, it will generally be much safer to
apply two ligatures;—one above,  and the
other below the wound.   The chances of
such an  accident will be  greater when
the artery is wounded  above the origin of
the  subscapular branch, which, from its
considerable size, and  its very free anas-
tomosis with the supra scapular, furnishes
a very free channel by which  the blood
may be transmitted from the subclavian
artery to  the  portion of the axillary be-
low  the  wound.   It will  be  advisable,
therefore, in most cases in which the ves-
sel is wounded  high  up, to apply a liga-
ture to both ends.   The  propriety of this
practice  is strongly indicated by the case
quoted above  from Charles  Bell,  in
which, notwithstanding  the axillary ar-
tery was  obliterated  where the ligature
was applied, the hemorrhage was renewed
through the communication of the colla-
teral  branches with the lower end  of that
vessel.
   When  the  artery  is wounded  higher
up, where  it is concealed by the pectoral
muscles,  much more difficulty will be en-
countered  in applying a ligature.   Still,
the same  precepts should  be  observed.
Free  incisions  should be made through
those muscles, upon the course of the ar-
tery; the  coagulated blood turned out
and the vessel carefully isolated from the
accompanying veins  and  nerves.   The
surgeon  should not hesitate to divide a
few muscular fibres, and  if the case de-
mand it,  it will be far better to cut the
pectoraiis minor boldly across, than to be
groping  fruitlessly in a deep and  narrow
wound in search of the artery, which is so
concealed  in  the  bed  of coagula as to
render its discovery  extremely difficult
By pursuing this  course, the  end of the
wounded artery in all cases where the in-
jury  is recent  may be  secured by liga-
ture ; and this should never be neglected
when the hemorrhage is profuse, or when
the blood is thrown into the surrounding
parts in such quantity as to threaten a
great degree of distension, and the subse-
quent development of inflammation  and
gangrene.  When neither of these condi-
tions exist;—when there is little or no
external hemorrhage, and but slight dis-
tension of the parts in the vicinity of the
wound by the accumulation  of blood with-
in the cellular tissue and beneath the pec-
toral  muscle,  it has been suggested, that
instead of resorting immediately  to the
operation, the case should be managed by
other  means, until either a consecutive
false  aneurism is developed, or the vessel
is spontaneously obliterated.  The cases
already quoted from Van Swieten  and
Guthrie,  prove,  that  under favourable
circumstances, the hemorrhage  may cease
without  the assistance  of  art and  the
wounded artery become impervious at the
seat of injury.   We have it in our power,
in some instances, to promote this  favour- 
AXILLA.  (Wounds of.)
able issue, by a properly adjusted  com-
press and other means, and if the case be
of a kind to promise any prospect of suc-
cess from such  a procedure, it certainly
should be preferred to a formidable opera-
tion, which, unfortunately, too  often fails
of success.   Occasionally, indeed,  a  fa-
vourable  termination  may  be obtained
without the  ligature,  even after a  false
consecutive aneurism has formed.  Saba-
tier (Medecine Operatoire, Nouvelle  ed.
par Sanson et Begin. HI. 124.) reports an
interesting case of this kind, in an officer
who had an  aneurism of the axillary ar-
tery, in consequence of a wound inflicted
by a sword.  It was treated by Valsalva's
method, together with the application of
powdered oak bark, wet with red wine, to
the  tumour; and was under this manage-
ment completely cured. Another instance
of an analogous  kind is recorded by Hodg-
son, on the authority of Gooch.  A child,
aged nine years, fell with an earthen dish
under his  arm,  a fragment  of which
wounded the axillary artery.   He was in
an instant deluged with blood, and fainted.
The wound was dressed,  and healed in a
few days;  but on removing the dressings,
it was found that  there  was some  hard-
ness at the site of the  injury, attended
with pulsation.   The tumour  and  pulsa-
tion gradually increased,  and at the end
of a tew weeks, the former  became so
large  as to project beyond the axilla.   It
then ceased to  extend—gradually sub-
sided, and  eight months afterwards  the
pulsation was   scarcely  perceptible,  and
the pulse  at the  wrist  very  feeble.  In
eighteen months, every vestige of the tu-
mour had disappeared, and the patient had
completely regained the strength of his
arm.  (Hodgson. Traite  des maladies des
 Arteres, &c. Traduit par Breschet. II.
352.)
   There are but  few cases, however, in
 which so fortunate an issue can be antici-
 pated. If the artery be not secured  at the
 time the injury is inflicted, and the blood
 should cease to  flow  externally, it  will
 either be driven extensively into the  cel-
 lular tissue, occasioning  enormous  tume-
faction of the whole axillary region,  shoul-
der, and upper  part of the arm, or a false
 consecutive aneurism will be developed,
 which will  increase rapidly,  and  render
the operation indispensable.   The first of
these conditions,  if not  remedied  by an
operation, is very apt to be followed by
 violent inflammation, and gangrene  of the
 whole extremity.   This can only be ob-
 viated by cutting down freely upon the
 course of the  artery, removing the coa-
                                   579

gula as far as possible, and securing the
severed ends  of the  vessel.   We  think
that such a condition can but rarely de-
mand amputation; yet it  is possible, that
in extreme cases, 6uch an expedient may
become necessary, as in the examples al-
ready referred to on the authority of Lar-
rey and Debaig.  When an aneurism has
formed, it will be better to resort  to the
ordinary  operation for that disease,—the
application of the  ligature some distance
above  the injury,  than to endeavour  to
find the  end  of the artery, when  it has
been  divided.   This course will be ren-
dered  preferable,  by the  changes deve-
loped  in the coats of the artery,  and  in
the surrounding structures, at the  seat of
the wound,  making  it difficult to isolate
the vessel on the one hand, while the lat-
ter, from its fragility, will be apt to break
under the ligature.   In all  other cases,
however, the ligature should be applied to
the ends  of the vessel in  the wound.
   It may also become necessary to apply
a ligature to the axillary artery, in conse-
quence of that vessel  being opened  by
sloughing  of  the  surrounding parts, in-
volving its tunics.  Guthrie remarks, that
after  the  battle of Salamanca,  he was
obliged to apply a ligature on the axillary
artery, which had  not bled  for  several
days, until the artery sloughed. (Op. Cit.
p. 304.)   Delpech (Chirurgie Clinique.
I. 7.  Berard.) tied  this vessel, in  conse-
quence of sloughing of the brachial ar-
tery:  the artery was cut by the ligature,
and the hemorrhage recurred: a ligature
was then  applied to the vessel below the
clavicle, and although the circulation was
re-established through  the collateral ves-
sels,  the  individual  was attacked with
hospital gangrene, and died.  In another
instance in which the axillary artery was
opened  by hospital gangrene, Galtier,
an assistant of Delpech, applied a liga-
ture to  the subclavian artery; but not-
 withstanding there was no renewal of the
 hemorrhage, the case terminated  fatally.
 (Loc. Cit. p.  18;  and  Berard, Diet,  de
 Med. 2d edit. IV. 490.)  Monteath was
 more fortunate in  a case in which  he
 tied  the  axillary artery,  on  account  of
sloughing of its tunics.  (The Lancet.  I.
730; and Berard, ut supra.)  Under such
circumstances, the ligature should always
 be applied upon a healthy portion  of the
artery, some distance above the situation
of the opening, as in the Hunterian ope-
 ration for aneurism.
    A review of all the cases in which a
 ligature has been  applied  to the axillary
 artery, on  account  of a  wound  of that 
580
AXILLA.  (Wounds of.)
vessel, shows conclusively, that the result
of the operation is far less favourable un-
der such  circumstances, than when it is
performed for aneurism.  The explanation
of this difference is obvious,  when  the
state  of the parts in the two conditions is
duly considered.  When the artery is tied
on account  of a wound,  there is not only
the injury inflicted by the operation, but
likewise that which renders its perform-
ance  necessary.  The surrounding parts
are sometimes extensively involved—per-
haps  violently lacerated,  and generally
filled with extravasated blood.  The veins
and nerves may be also injured, rendering
the parts more  liable to  take  on  a high
degree of  inflammation  and sloughing.
These  are,  indeed,  consequences  almost
inevitable, after the infliction of so much
violence upon  the parts; but there  are
other circumstances  which have consider-
able participation in producing the dispa-
rity of success in the two cases  alluded
to.   In aneurism, the long-continued im-
pediment to the  passage  of  the blood
through the main artery,  produces a gra-
dual dilatation of the collateral vessels, so
that when the ligature is applied,  the cir-
culation is carried on with sufficient free-
dom through the anastomosing vessels, to
maintain the nutritive action of the parts
beyond the  point of obstruction.   When,
on the contrary, a ligature is  applied on
account ofa wound of the axillary artery,
this preparatory dilatation of the  collate-
ral vessels not having preceded, the sup-
ply of blood is cut oft" and the limb is apt
to fall into a state of gangrene. The truth
of this explanation is corroborated by the
result of several cases, in which  the ar-
tery  has  been  tied  under the  circum-
stances mentioned.   This happened in a
case  in which Desault  tied this vessel,
by making an incision through the pecto-
ral muscle.  (Desault's Surgical  Works.
Translated by Ed. Darrel Smith.  I. 478.
Philada. 1814.)   Debaig cites two cases,
in which gangrene  of the arm followed
the operation (Berard.  Diet, de Med. IV.
490.); and in the case ofa child, in which
the artery  was tied  by Maunoir, three
fingers were destroyed  by mortification,
notwithstanding the  operation was crown-
ed with success.  (Berard.  Loc. Cit.)
   5.  Wounds of the  veins of the  Axilla.
The veins of the axilla may be wounded,
either by violence accidentally inflicted
upon the parts, or in the performance of
surgical operations;  and such injuries are
sometimes associated with a wound of the
axillary artery, the  brachial  plexus of
nerves,  and other  important  structures
contained within the axillary region. The
ill consequences liable to result from such
an accident are, venous hemorrhage; the
introduction of air into the veins, and sud-
den death; phlebitis; and, finally, when
the artery is wounded simultaneously, the
development of an aneurismal varix, by
the propulsion of the stream of blood from
the latter vessel into the vein.
  Venous hemorrhage from the axilla can
be readily distinguished from  arterial, by
the dark colour of the  blood, and by its
flowing away in a steady current rather
than being thrown out in jets.  It can be
generally commanded by pressure, even
when the axillary vein is wounded, and if
the surgeon be called in time, is  not usu-
ally near so formidable an accident as
when the corresponding artery is injured.
(See  Hemorrhage,  and Wounds of the
Veins.)
  The accidents resulting from the intro-
duction of air into the veins have been
already considered by Professor Warren.
(See  article Air.)  A case is there  re-
ported,  in  which  death  was suddenly in-
duced by the division  of a vein in the ax-
illa, which  was immediately followed with
a gurgling sound, resulting from the  in-
troduction  of air  into the veins.  Other
cases of a similar kind have been  observed
by  Beauchene,  Castara, Clemot, and
Delpech.   In the first,  the accident hap-
pened during the extirpation  of a tumour
from  the shoulder, involving a portion of
the outer extremity of the clavicle.  The
vein was wounded in attempting to  re-
move the diseased bone.  Castara's case
was a tumour occupying the dorsum of
the scapula, and the vessel wounded was
a branch communicating with  the sub-
scapular vein.  In  the  instance  reported
by Delpech, the operation which led to
the accident was  amputation of the shoul-
der joint, performed on account  of great
hypertrophy of the vessels of the arm.
Death ensued in every instance, except
the one reported by Clemot, in a  few
minutes. (Ollivier. Diet, de Med.  2d ed.
II.  68.)
  Phlebitis attacking the axillary  vein,
may be regarded  as almost necessarily fa-
tal, on  account of the  proximity of the
heart   All necessary information in  re-
gard to this subject will be found under
the article treating of the pathology of
the veins, and need not be detailed here.
We shall  speak  of aneurismal varix of
the axillary vein in a subsequent part of
the present article.
  6.  Wounds of the nerves of the Axilla.
The same causes  that are  instrumental in 
AXILLA.  (Wounds of.)
581
inflicting a wound upon either the axil-
lary artery or vein, or both at the same
time,  may  implicate the  corresponding
nerves.   The  latter,  however,  may be
wounded, and  the  veosels escape;  al-
though when the injury is inflicted  by a
sharp instrument or gun-shot  it will sel-
dom happen that one will  be implicated
without the  other.  These nerves are also
exposed  to  violent contusions, and some
of them are  probably sometimes lacerated,
in dislocations  of the shoulder  joint  in
fractures of  the neck of the humerus, and
in violent attempts to replace the dislo-
cated bone.   When  a dislocation of the
head of the  humerus downwards has been
allowed  to  remain for several weeks or
months, the bone contracts very intimate
adhesions with  the  axillary vessels and
nerves, so that  any attempt made to re-
turn the bone, by breaking up  its adventi-
tious adhesions by force, may  not only la-
cerate the  artery, as already indicated,
but likewise inflict a corresponding injury
on the nerves.
  In whatever  way  the axillary nerves
be wounded, the consequence  is, paralysis
of the member, when all the nerves are
wounded, or of particular muscles, when
only one or more of the nervous chords
are  implicated.  The paralysis  involves
both sensation  and motion;—the  arm is
numb  and powerless; its  temperature is
often diminished; and in many instances,
the  muscles become  greatly atrophied.
The loss of power, however, is sometimes
only temporary; for although  a nerve be
completely  severed  by a  cutting instru-
ment, it has been satisfactorily ascertain-
ed, that reunion between the divided ends,
will, in process of time, restore the func-
tion.  This  will be more apt to take place
in simple incised wounds, than  in those
which  are  contused and  lacerated, and
attended  with  loss  of  substance.  (See
Nerues, pathology of; and Descot, sur
les affections locales des  nerfs, &c.  Pa-
ris, 1825.)
   Very little  can be done in  the way of
treatment in such cases.  At the time the
injury is inflicted,  the wound must be
managed on general principles, and if, as
sometimes  happens,  when a  nerve has
been but partially divided, or otherwise
injured, there  should  be  great pain,  it
must  be allayed by opium.   Artificial
warmth may  sometimes be necessary to
maintain the temperature of the member;
and with the view  of promoting  the re-
establishment  of the nervous  influence
over the muscles, after sufficient time lias
                  49*
elapsed for reunion to be  completed, fric-
tions and galvanism should be resorted to.
  These nerves sometimes sustain an in-
jury of a much  more formidable  charac-
ter, from violent efforts  made  to reduce
ancient dislocations of the shoulder joint.
The axillary plexus having connected it-
self by adhesions with the head of the
humerus, when  the extending  and  coun-
terextending force  is applied to the head
of the bone, the nerves  being  unable to
yield at the point of adhesion, are dragged
with the member, and their roots are torn
asunder from the spinal chord.  This very
serious accident was first particularly no-
ticed  by Flaubert, of Rouen, who  has
recorded a fatal case in which it occurred
—besides others, in which the violence
was followed by paralysis and wasting of
the limb.  (Repertoire d'Anat. et de Phy-
siologie  pathologique.   III.  55.   Paris,
1827.)  In one of these cases, the luxa-
tion had existed five weeks, and  was re-
duced by Flaubert, in the Hotel-Dieu of
Rouen, by means of extension made by
eight  pupils of the house.   At first,  the
individual  cried out violently on  account
of  pain;  but soon  her  ability to  do so
seemed to be overcome,  by the compres-
sion of the chest, and a sense  of suffoca-
tion.   Immediately  after the  reduction,
an emphysematous  condition diffused it-
self from above the clavicle to  the middle
of the back; — the  countenance became
pale;  the pulse  feeble; and nausea super-
vened. At the same time, a sense of cold-
ness  and numbness was experienced in
the left thigh and leg, which were so sen-
sitive, that the patient cried out with pain
on the slightest touch.  This was on the
8th of December, und on  the  22d death
took place.
   Besides extensive injury of the muscles
and other parts, the following evidences
of violence were presented by the nerves:
 they were agglutinated  on a  level with
 the arm-pit,  by dense cellular tissue, pre-
senting  the appearance of having been
 for some time the seat of a moderate de-
 gree of inflammation.  This tissue formed
 a kind of sheath for the nerves, above and
 below, but gradually diminished in quan-
 tity in both directions.  Near the scaleni
 muscles, the ruptured extremities of the
 nerves were discovered.   The four  last
 pairs  composing the brachial plexus were
 entirely severed; the first pair  had es-
 caped unhurt.  Those which were severed
 had their roots torn from their connexion
 with  the spinal chord, and the filaments
 by which they take  their origin, could be 
582                         AXILLA.  (Aneurism of.)
distinctly recognized.  The ganglions at-
tached to the posterior  roots could like-
wise  be distinguished, and  were  drawn
out from the intervertebral foramen;  but
presented no other appreciable alteration.
  Flaubert reports examples of other
luxations, in which the efforts made to ef-
fect the reduction, were followed by per-
manent paralysis; and the conclusion at
which he arrives is, that  many cases of
paralysis of the arm, usually attributed to
the luxation itself, are owing to the injury
inflicted by the  attempts made to replace
the bone.
  Bibliography.—Flaubert. Mimoire surplu-
sieurs cas de luxation, dans lequels les efforts pour
la riduclion out iti suivis d'accidens graves; in
Breschf.t's Repertoire a"Analomie et de Physio-
logie Pathologique.  111. 55.  Paris, 1827.
  7.  Aneurism  of the  axillary  artery.
The  axillary artery  is liable  to  all  the
forms of aneurism that take place in other
portions of  the  arterial system.  Several
cases of traumatic aneurism of this ves-
sel have been already quoted; but it is,
besides, very subject to that form  of  the
disease which takes  place  spontaneously.
The liability of the axillary artery to this
disease, though greater than that of many
vessels of both larger and  smaller size, is
nevertheless far less  than that of some
others.
  The popliteal and  femoral arteries  ex-
hibit a remarkable proneness to aneurism;
—so  much  so,  that of one hundred and
seventy-one cases of this disease collected
by  Lisfranc, fifty-nine were popliteal;
fifty-four femoral; and fourteen axillary.
(Lisfranc  Des diverses methodes et des
differens procedees pour Vobliteration des
Arteres, &c.  Paris, 1834.)   When,  in-
deed, we reflect upon the intimate rela-
tions of this vessel  with the shoulder
joint; its great liability to  suffer injury in
the various, and often violent, movements
of the upper extremity; the accidents to
which it is liable in the displacements of
the articulations; and the diseases and in-
juries to which the  axillary region is ex-
posed ; it is  matter  of surprise, that  the
artery in question is  not oftener attacked
with  aneurism, both traumatic and spon-
taneous.  The liability of attempts to re-
duce ancient dislocations of the shoulder
joint to lacerate the coats of the axillary
artery,  has  been  mentioned in the  pre-
ceding remarks.  Pelletan mentions two
instances, in which aneurism of this ves-
sel was induced by the individuals being
in the practice of suspending themselves
by the arms, on  account of a  rheumatic
affection.   In the same manner, the dis-
ease is occasionally developed, where the
coats of the  vessel are diseased,  by the
exertion of lifting  heavy burthens,—and
by blows,  contusions,  and other injuries
inflicted upon the axilla.
  Aneurisms of the axilla, when once de-
veloped, increase with great rapidity, and
soon attain a very  large size.  This is a
natural consequence of the slight resist-
ance afforded by the adjacent parts, and
the looseness of the cellular tissue which
surrounds the vessel.  The pectoral mus-
cles are forced forwards,  and  under the
distension  of the tumour,  their fibres be-
come attenuated: the scapula is protruded
backwards and outwards from the thorax,
—the shoulder and  clavicle upwards; and
the natural concavity of the axillary fossa
is effaced; the skin being forced outwards
by the distension of the  tumour.  When
the latter  has  attained a large size, the
deformity  resulting from  the  derange-
ment of the natural  relations of these
parts is very  great The shoulder is tilted
upwards,  so  as to be  elevated  sensibly
above the level of the one on the opposite
side: the  scapula is forced backwards
from the  ribs to a considerable distance;
and the whole shoulder and limb, rendered
numb and tumid, by the pressure upon the
veins,  lymphatics,  and  nerves,  are de-
prived of the faculty of motion, and be-
come completely useless;  or if movable,
every attempt to exercise  the arm is pro-
ductive of great pain and difficulty. Some-
times, indeed, the long-continued pressure
of the tumour upon the  nerves, produces
a notable degree of atrophy of their sub-
stance; and  the operation of the same
cause upon the veins and lymphatics, ob-
structing the free return of the blood and
lymph  from  the  extremity, occasions a
high degree of oedema of the whole mem-
ber, — which is thereby  rendered  stiff,
painful,  and  sometimes livid  and  cold.
The pulse at  the wrist is also considerably
modified; it  is generally very weak, and
in many cases cannot be felt.
  The direction in which the tumour ex-
pands, is somewhat influenced by the por-
tion  of the artery from which it takes its
origin.  When  it springs  from the outer
portion  of the  vessel,  meeting  with but
little resistance from the skin spread over
the axillary fold, it of course protrudes in
that direction with  great facility—at the
same time that it forces the pectoraiis ma-
jor forwards,  and the latissimus dorsi and
teres major,  together  with the  scapula,
backwards.   But even then, it cannot at-
tain  a lar?e size without producing consi-
derable elevation of the shoulder, because 
AXILLA.  (Aneurism of.)
of the  resistance afforded  by  the  skin
where it is reflected off from the surface
of the ribs.  If, however, it proceeds from
the portion of the artery comprised within
the claviculo-pectoral  portion of tlie re-
gion,  it  cannot so  readily expand out-
wards.  It is resisted in front by the pec-
toraiis major and the costo-coracoid liga-
ment ; above by the  clavicle; inwards by
the ribs; and outwards by the  pectoraiis
minor muscle, where it passes in front of
the vessel.  Here then, it is more apt to
be obscure or concealed in the  early part
of its development; to proceed less ra-
pidly ; but at the same time to inflict more
injury on  the  surrounding  parts.   The
vein and nerves are forcibly compressed,
—the former sometimes obliterated: the
pectoral muscles are attenuated ; the cla-
vicle is forced upwards, so as to encroach
greatly upon the neck, and  is sometimes
nearly destroyed by the  encroachments
of the  tumour;  the scapula  is  carried
backwards,  putting  the serratus magnus
upon the stretch, and this muscle is occa-
sionally completely atrophied by the con-
stant pressure of the aneurism.  The sub-
scapularis  muscle  is  frequently  wasted
from  the same cause, and in extreme
cases, the scapula itself, as well as the
ribs, are extensively eroded.  Lawrence
has reported a very interesting case, cal-
culated  to show the  extent of the ravages
that may be produced by an axillary an-
eurism.  The tumour occupied the whole
axilla, and extended upwards to the neck.
The clavicle and upper ribs were denuded
and eroded,  and about three pints of co-
agulated blood were evacuated from the
tumour, besides some masses of fibrinous
concretions.  A process of the tumour was
prolonged upwards,  in the inferior portion
of the neck, above the sternum; and a
second, of larger size, extended into the
thorax,  between the first and second ribs,
tlie convex surface of which adhered  to
the lung. (Lancet, and Berard, Loc. Cit.
p. 492.)   Two cases are also reported by
Colles, in one of which the scapula was
rough and  denuded, while in  the other,
the  aneurismal sac communicated with
the cavity of the shoulder joint; the adja-
cent  portion of the  capsule  being  de-
stroyed.  (Edinb. Med. and Surg. Journ.
1815; apud Berard, Loc. Cit.)  In a case
reported by Pelletan, the pressure of the
tumour upon the axillary vein,  obliterated
that vessel, which was found  closely ad-
herent to the sac.  If the disease be suf-
fered to proceed unchecked, it  finally ter-
minates by  rupture, as is the case with
                                   583

aneurisms of other parts of the body, and
the patient is destroyed by hemorrhage.
  In some cases, axillary aneurism termi-
nates more  favourably, even though the
assistance of art be entirely withheld; the
artery above the tumour, or the sac itself,
being entirely obliterated  by the sponta-
neous and  unassisted  powers of nature.
We have already, in speaking of wounds
of the axillary artery, cited cases in which
false  consecutive aneurisms of that ves-
sel  were cured without an operation, or
dissipated  by  the  method  of  Valsalva.
Several others, of an analogous character,
have  been  recorded.   In some  of  them,
the cure was  effected  by  an obliteration
of  the  axillary artery itself, while in
others, the same termination was induced
by the subclavian artery becoming closed
above the tumour;  the blood,  under both
conditions,  being diverted into the  colla-
teral vessels.  An individual entered St
Bartholomew's Hospital, labouring  under
an aneurism of the axillary artery; but as
he had previously suffered from a disease
of the same kind on the other side, which
disappeared spontaneously, he refused  to
submit  to an operation.  The  aneurism
finally ruptured, and he was destroyed by
hemorrhage, when it was found, that the
aneurism  which  had  formerly  occupied
the axilla of the opposite side, had been
cured by spontaneous obliteration. (Hodg-
son.  Op. Cit. II. 94.)  The instances  in
which aneurism of the axillary artery is
cured spontaneously by obliteration  of the
subclavian are numerous, and  will be re-
ferred to under another head.   (See Cer-
vical region.)  But it sometimes happens,
that even when obliteration of the artery
takes place, the aneurism continues to ex-
pand, and to undergo  the usual changes,
until its walls finally  give way, and the
patient is destroyed by the loss of blood.
In  a case of aneurism examined by Pel-
letan,  he found the axillary artery oblite-
rated, and the tumour so large as to reach
the clavicle.  Immediately below the an-
eurism, the artery was converted into  a
ligamentous substance, and would not ad-
mit even the smallest-sized probe. (Cli-
nique Chirurgicale.  II. 93.)  Monro also
witnessed  a case, in which an  aneurism
occupying the axilla, descended as low as
the arm. It finally ruptured, and destroyed
the patient by hemorrhage,  and on ex-
amining the parts, the artery was found
communicating with the aneurismal sac,
but at  the  same time it continued along
its posterior surface,  where it was almost
impermeable  to the extent of half an 
584
AXILLA.  (Aneurism of.)
inch.   Below the point indeed, at which
the vessel communicated with the tumour,
it was nearly obliterated by an adherence
of its tunics.  (Edinb. Med. Essays.  III.
196;  and Hodgson.)
  The diagnosis of aneurism in this re-
gion,  is sometimes attended with so much
difficulty, that serious  mistakes  have oc-
casionally been  made; — aneurismal tu-
mours having been opened for abscesses,
and the axillary or subclavian artery tied,
on account of tumours, which were after-
wards found to possess  nothing of an an-
eurismal character.  In one of the cases
reported by Pelletan,  a large aneurismal
tumour of the axilla was  mistaken for an
abscess, and with the view of drawing off
its  contents gradually, a  small  puncture
was made, when, instead  of pus, a jet of
arterial blood issued from the wound. The
pressure which was resorted to, in order to
arrest the flow of blood, produced slough-
ing, and  a fatal hemorrhage ensued.  (Be-
rard. Loc.  Cit.)  It  is also stated  that
Ferrand,  in  one case, made  a  similar
mistake, and  plunged  a bistoury into an
axillary aneurism, presuming it to be an
abscess.  (Richerand.  Nosograph. Chi-
rurg.  IV. 75.) When  the tumour is seat-
ed beneath the  pectoral muscles,  not be-
ing very conspicuous externally,  it is not
unusual  for it to be  mistaken  for some
other affection, or if it be attended with
pain and difficulty of moving the limb, to
treat  it for rheumatism. In one case, Ba-
ker, of the New Castle Infirmary,  applied
a ligature  to  the axillary artery on ac-
count of a tumour of that region which
was supposed to be aneurism, but which
it was afterwards ascertained was fungus
hematodes.  (The Lancet. II.  210.)  In
1830, the subclavian artery was tied by
Earle, at St. Bartholomew's Hospital, on
account  of a tumour of the axilla which
was supposed to be aneurism.  The indi-
vidual recovered from the effects of the
operation, but died in 1835.  On  examina-
tion,  it was discovered that  the tumour,
which was  situated below the clavicle,
along the course of the  brachial plexus
of  nerves, was  oblong,  two inches in
length, and  about an  inch and  a  half in
width. Its surface was white, and within,
it consisted of a grayish dense substance,
divided  into  separate  portions by white
lines  extending through  it in various di-
rections: the  axillary  artery was firmly
united to one side of the tumour by dense
cellular tissue, and the subclavian artery,
at the seat of  the ligature, was closed.
(Lond. Med. Gazette.  VI. 241.  1830, and
XVI. 514. 1835; and  Am. J.  Med. Sc.
XVIII. 516.)
  The treatment  of aneurism  of the ax-
illary artery must be conducted upon the
same general principles that  direct the
management of the  disease in other situa-
tions.  These have  been discussed in the
article Aneurism  (q. v.),  and need not be
repeated here. We  have already observed,
that a spontaneous cure is occasionally
effected, and we  have, besides, quoted a
case from Sabatier, in which a false con-
secutive aneurism was effectually reme-
died by the  method of Valsalva.   An-
other instance,  in which the disease was
cured in a similar manner, has been re-
ported by Pelletan ; but when we con-
sider the fatal  tendency of the disease,
and  the numerous  obstacles to  success,
either under the unassisted powers of na-
ture, or the ordinary means of art, exclu-
sive of the ligature,  we  should be cautious
how far we confide  in  feeble and tempo-
rizing measures.  When the resources of
surgery were more  limited, the treatment
of axillary aneurism consisted for the most
part in the  rigid employment of antiphlo-
gistic means, according to the method of
Valsalva, and when these failed, ampu-
tation at the shoulder joint was resorted to
as a last refuge.  But the triumphs of art
having long since demonstrated, that even
the  large arterial trunks may be safely
and  securely included in a ligature, for
the cure of aneurism,  and the arrest of
hemorrhage,  there are  few circumstances
that would justify  a  reliance upon any
course of treatment, to the exclusion of
the operation, and  none, perhaps, to au-
thorize  amputation  at  the shoulder joint.
We have quoted  a  case  above, it is true,
in which Larrey resorted to this latter
expedient  and Debaig has reported an-
other ; but if it  in these cases afforded the
only chance,  it was because of the neglect
of the ligature at  the proper  season, by
which the tumour was allowed  to increase
to such an enormous size, as to render  it
difficult, or  impossible, to reach  the ar-
tery.  If, therefore, amputation ever be-
comes necessary,  it is under such circum-
stances, and  the  surgeon who would al-
low the disease to advance thus far, would
justly merit  to  be censured for his negli-
gence,  unless impelled to such a course
by the misguided fears, or the obstinacy,
of the  patient.   It should be  constantly
borne in mind, that  the safety of  the pa-
tient depends upon the  vessel being se-
cured  above the  aneurism,  either below
or above the  clavicle, and that the longer
the operation is deferred, the greater will
be the difficulties  of achieving  it with suc-
cess.  If the aneurism  be  situated low
down, it will  rapidly attain such a size, as 
                        AXILLA. (Ligature of Artery.)

to render  it impracticable to apply the
ligature  below the clavicle;  and as the
same cause  will  force the  clavicle up-
wards, if the operation be too long de-
layed,  this displacement  will become so
great  that the artery cannot be reached
between the  clavicle and the scaleni mus-
cles.
  These considerations strongly indicate
the importance, in all cases of axillary an-
eurism, of resorting early to the ligature.
The obstinacy of the patient alone, some
peculiar  condition of the constitution, or
of the parts  affected, contraindicating an
operation, can justify any other procedure.
Under these circumstances, the general
treatment may be  confided in, but seldom
can we indulge in any sanguine hopes of
success,—and if the tumour be allowed to
become  so diffused,  or  the  clavicle so
much displaced, as to  render the applica-
tion of  the ligature  impracticable, we
question much whether amputation would
better the condition, since the artery  is
diseased so far above  the  level of the ar-
ticulation,  that we do not know how the
hemorrhage could be commanded.
  8.  Ligature  of the  axillary  artery.
This may become  necessary, either on ac-
count of a wound implicating that vessel,
or for the cure of an aneurism of the up-
per portion of the  brachial, or the  lower
portion of  the axillary artery.   When an
aneurism of the  brachial artery is situated
near the  attachment of the  latissimus
dorsi, the ligature must be applied to the
axillary artery;  but if the disease  be still
higher, so  as to implicate the latter vessel
itself, then the ligature must be applied
to it in the claviculo-pectoral triangle,  in
the space between the upper edge  of the
pectoraiis  minor  and the  clavicle. Fi-
nally,  if the aneurism  extend so high,  as
to leave no room for the application of the
ligature at this point  it must  be  placed
upon the subclavian artery, above the cla-
vicle,  and on the outer side of the  scale-
nus muscle.  This last operation will be
generally demanded, in all cases  of axil-
lary aneurism situated on a level with,  or
above, the pectoraiis minor muscle.  But
as it can be better described in connexion
with the region upon which it is perform-
ed, although resorted to  for the cure of
axillary  aneurism, we shall refer  for all
details concerning it  to  the  article Cer-
vical region (q. v.).
  It therefore only remains for  us to con-
sider the ligature of the axillary  artery.
There are  two points at which  it is prac-
ticable to secure this vessel.  The first is
in the  fossa of the axilla, below the pec-
                                    585

toralis minor;—the second, in the clavi-
culo-pectoral triangle,  between the upper
edge of that muscle and the clavicle. The
portion of the artery which is covered by
the pectoraiis minor might also be tied;
but as it would be necessary, in the per-
formance of the operation, to cut the pec-
toraiis minor across, and as, besides, the
principal thoracic branches are  given off
near  it, the vessel is  never tied in  this
situation.  The second  point only is avail-
able, when  the condition calling for the
ligature is an aneurism occupying the ax-
illa,  except when  it is determined to tie
the vessel on the distal side of the tumour,
as was practised  in one case by Dupuy-
tren.  But  when an aneurism of the  bra-
chial artery is situated  so high, as to leave
no room for the application of a ligature
upon that vessel,  the  axillary artery may
be tied at the first point indicated.
  Cases in  which a ligature was applied
to the axillary artery by Hall, White,
Desault,  and  others, on  account  of
wounds, have  been already  mentioned.
The individual upon whom Hall operated
recovered;  but White's  case terminated
fatally by gangrene; — an event  which
was scarcely avoidable, on account of the
rude operative procedure adopted. A nee-
dle,  armed  with a ligature, was plunged
deeply through the soft parts in the axilla,
with  the  object of including a portion of
the surrounding  structures in  the knot
On examination after death, it was found
that three  of the chords of the axillary
plexus of nerves were tied up with the
artery, and that  the  vein was  wounded.
(Bell. On  Wounds. 3d edit  p. 60.)  De-
sault's case promised at first to be more
fortunate; but erysipelas seized upon the
shoulder and arm on the fourth day,  and
the patient  was finally destroyed by gan-
grene.  Pelletan made an  ineffectual
effort  to secure the axillary artery below
the clavicle, on account of a large axillary
aneurism.   He at first proposed to detach
the pectoraiis major from the clavicle, and
turn  it downwards; but being persuaded
that the aneurismal tumour, in being de-
prived of the support afforded by this mus-
cle, would be apt to burst before the liga-
ture could  be applied, he resolved to in-
clude  a portion of the  fibres of the pecto-
ral muscle   in  the ligature;   but after
plunging  an armed  needle  repeatedly
through the parts, without securing the
artery, he  desisted, and the  individual
died on the  twentieth day after the opera-
tion. (Clinique Chirurgicale. II. 49.) The
first case  in which the  axillary artery  was
successfully tied, on account of aneurism, 
586                     AXILLA.  (Ligature of Artery.)
was one on which the operation was per-
formed by Keate.  The aneurismal tu-
mour had  already ruptured,  and the he-
morrhage  was  commanded  by pressure
upon the first rib.  An  incision was car-
ried obliquely through the pectoral  mus-
cle, so as to expose  the artery, and  a
curved blunt-pointed needle, armed with
a double ligature,  was passed, as was sup-
posed, beneath  the  vessel.   On drawing
it  however, the artery still pulsated, and
a second ligature  was passed nearer the
clavicle, which being carried deeper, com-
manded  the vessel.   In a few days, the
swelling of the arm began to subside; the
wound suppurated  ; and the ligatures came
away with the dressings. The arm finally
regained, in a great measure, its power
of motion, and recovered its feeling. (Med.
Review  and  Magazine, 1801; and Art
Aneurism, in  Cooper's Surg. Diet.)
  Since  that  period, the axillary artery
has been tied beneath the clavicle in other
instances.  The operation was performed
successfully, in  1815,  by Chamberlaine,
of Kingston, Jamaica, on account of trau-
matic aneurism  of the axilla (Med. Chi-
rurg. Transact. VI.  128.); and more re-
cently, Roux applied a ligature to the ax-
illary artery  below  the  clavicle, on ac-
count of an aneurism occupying the lower
part of  the  axilla.  (Berard.  Diet, de
Med. IV. 497.)  The  volume of the tu-
mour subsided promptly, and the patient
recovered.   To these  cases,  should be
added two  others,in which it is stated by
Guthrie, that the  patients died under the
attempts to apply the ligature, the vein
being injured  in both instances. (Op. Cit.
p. 265.)  It is not mentioned, however,
for  what purpose  the operation was per-
formed, whether for  aneurism,  or wound
of the artery.   The  same remark may be
made in reference to two other fatal at-
tempts of the same kind;—one mentioned
by Roux, as having happened at the H6-
pital Beaujon; the  other by Delpech. In
1829, Dupuytren applied a ligature  to
the axillary artery, on  account  of an an-
eurism of the subclavian, situated above
the clavicle.   The ligature was applied
between  the  tumour  and the capillary
vessels, according  to the  method of Bras-
dor ; but the individual survived only nine
days.  (Lecons Orales de Clinique; and
Lond. Med. Gazette, XII. 857.)
  The operation of applying a ligature to
the subclavian artery above the clavicle,
and on the outer  side of the scalenus mus-
cle,  has  been far more frequently  per-
formed, and should  be  preferred  in all
 cases of axillary aneurism.  As, however,
 the  method of operating in that situation
 will be described  in the article Cervical
 region, we  shall only describe  here the
 method of tying  the  axillary artery, be-
 low  and above the pectoraiis minor  mus-
 cle.
   Ligature of the axillary artery in the
 outer  third  of its extent. — Lisfranc's
 Method. — In this operation, the artery is
 exposed in the hollow of the axilla.  It is
 applicable to  those cases of aneurism of
 the  upper portion of the brachial artery,
 in which sufficient space  intervenes be-
 tween the tumour  and  the pectoraiis mi-
 nor,  to admit of the application of a liga-
 ture ;—also to wounds of the correspond-
 ing  portion  of the vessel.
   The  patient is  placed  upon his  back,
 and  the arm forcibly extended from the
 body.  The space between the latissimus
 dorsi and the pectoraiis major being di-
 vided into three  portions,  a longitudinal
 incision, of about three inches in length,
 commencing on a level with the head of
 the  humerus,  is  carried  along  the line
 corresponding to the union of the anterior
 with the middle third of the space  men-
 tioned above.   The skin and cellular tis-
 sue being thus divided, the axillary plexus
 and  the median  nerve  are brought into
 view,  with  the  artery immediately be-
 neath the latter.   Having advanced thus
 far, the artery is  cautiously isolated  from
 the vein and nerves,  using the scalpel or
 bistoury as little as possible, and the  liga-
 ture passed  from behind  forward,  by a
 common aneurism needle.  (Coster, Ma-
 nuel des Operations Chirurgicales, p. 30.
 Paris, 1835; and Ogier  and Logan, Com-
pend. of Operat. Surg.  Part II. p. 35. pi.
 vii.  Charleston, 1835.)
  Ligature of the axillary artery between
 the clavicle and the pectoraiis minor.  A
 variety of procedures has been proposed
 for the  performance  of  this operation.
 Chamberlaine made  two incisions;  one
 along the lower edge of,  and parallel with,
 the  clavicle,  three inches in length;—
 the  other along the line of demarcation
 between the deltoid and pectoraiis major,
 which intersected the first, near its mid-
 dle.   In this  manner, a small flap  was
 formed,  which was turned downwards.
 Desault  and  Roux recommend an inci-
 sion  to be made on the  inner side of the
 coraco-deltoid line,—then the division of
the pectoraiis major upon  a grooved di-
rectory ; and,  finally,  the division of the
pectoraiis minor where it reposes in front
of the  artery.   This is the most difficult 
AXILLA.  (Ligature of Artery.)
and certainly the most objectionable pro-
cedure of all that have been advised.  The
following methods are far preferable.
   a. Hodgson's Method.  The patient be-
ing seated on a chair,  with  the shoulders
inclined a little backwards,  an assistant
standing behind, compresses the subcla-
vian artery where  it  runs  over the first
rib. The  operator makes a semilunar in-
cision,  with the  convexity downwards,
commencing about  an  inch from the ster-
nal extremity of the clavicle, and extend-
ing outwards four inches, to the line  be-
tween the pectoraiis  major  and the del-
toid.  The first incision divides  the skin
and cellular tissue; a second, of the same
extent  and carried in  the same direction,
traverses the  fibres of the pectoraiis ma-
jor.  The semilunar  flap,  thus formed,
being dissected up, the pectoraiis minor is
exposed, above which the artery can be
felt pulsating, having the vein below, and
when full, somewhat in front and the ax-
illary plexus behind, with one of its chords
in contact with the vessel.   The artery
being then isolated by means of a blunt
instrument the ligature is passed beneath
it and tied. (Op. Cit.  II. 105.)
   No possible  advantage can result from
giving  the incision the curved  direction
here indicated, and the operation has,  be-
sides, been objected to, on account of the
necessity it incurs of sacrificing so large
a portion of the fibres of the pectoral mus-
cle.  Guthrie remarks, moreover, that it
is  so extremely difficult,  that  he had
known  two individuals die under the at-
tempt to pass the ligature.
   b. Method of Chamberlaine, Langen-
beck, Rust, Chelius, Manec, &c.   To
this head  may be  referred several opera-
tive procedures,  which, though  differing
in  some slight particulars,  are neverthe-
less founded upon the  same general prin-
ciples.  Chelius proceeds  in the follow-
ing manner: the patient is seated, with
the shoulders drawn backwards, while an
assistant compresses the subclavian artery
over the first rib.  An  incision, commenc-
ing an inch from the sternal  extremity of
the clavicle, is carried outwards below
the lower part  of that bone, towards  the
coracoid process, to the furrow which  se-
parates  the pectoral from the deltoid mus-
cle. The skin and cellular tissue are first
divided,—then the fibres of the pectoraiis
major, and the pectoraiis minor is brought
into view.   The  point of the  finger,  in-
serted between the coracoid process and
the lower edge of the clavicle, discovers
the artery, together  with  the  brachial
                                   587

plexus.  The vessel  is  cautiously sepa-
rated,  and the ligature passed beneath it
by  means  of Deschamp's aneurism nee-
dle. (Chelius.  Handbuch der Chirurgie.
I. 875.)  Langenbeck's procedure only
differs from  this,  in the incision being
commenced beneath  the central part  of
the clavicle.  (Nosologic und Therap. der
Chirurg. Krankheiten. IV. 221.)  Rust
makes an  incision two and a half inches
in length, and one fourth of an inch below
the clavicle, which  is carried  obliquely
outwards towards the tip of the coracoid
process.   By this  incision,  one half the
clavicular portion of the pectoraiis major
is divided, together with the tendon of the
pectoraiis minor.  This latter step of the
operation is  altogether superfluous.  Bu-
jalsky and  Manec, with  the view  of
avoiding the  cephalic vein, which runs in
the furrow between  the  pectoraiis major
and the  deltoid, recommend the incision
to be  commenced at  that point, and car-
ried inwards.
  c. Marjolin and Lisfranc's Method.
The patient being  properly placed,  in
either  a sitting or a recumbent posture,
an  assistant  compresses the  artery  as
above, and the arm  is carried  outwards
and backwards,  in order to put the pecto-
ral  muscle on the stretch.  The operator,
searching for the depression  correspond-
ing to  the line  of separation between the
clavicular and 6ternal portions of the pec-
toraiis major, commences an incision half
an inch outwardly from the sternal extre-
mity of the clavicle, which  is carried  in
the direction of the line indicated, to the
extent of three inches.  The two portions
of the pectoral muscle are then separated
in the direction of their fibres,  from one
end of the incision to the other, and if no
natural line  of demarcation can be per-
ceived,the knife must be carried between
the fibres.  This done, the arm is brought
down to the  side of the body, in order to
relax the muscle, and give greater extent
to the aperture.  Near the  inner third of
the sternal extremity of the clavicle, the
vein is found in front of the artery, which
is often covered with a considerable quan-
tity of adeps and  cellular tissue.   Care
must be taken, not to injure this vessel;
and to avoid this,  it will be advisable to
isolate it with the handle of the scalpel,
the finger-nail, or the point of a directory;
after which,  the ligature is passed from
below upwards. (Coster. Op. Cit.  p. 30.)
This last step  of the operaticn will be
greatly facilitated by the use of some one
of the ingenious contrivances which have 
588
AXILLA.  (Aneurismal Varix.)
been devised within a few years, for pass-
ing a ligature beneath deep-seated arte-
ries. (See Ligature, and Cervical region.)
  It is of but little consequence, which of
the two last procedures be adopted. Each
has its  advantages  and disadvantages.
The method of Langenbeck and Chelius
affords greater facility in reaching and se-
curing the vessel; but  it is liable to the
objection of sacrificing the fibres of the
pectoral muscle.   Marjolin  and  Lis-
franc's  method  is not obnoxious to the
last inconvenience; but it gives  rise to
greater  difficulty in securing the vessel.
When the aneurism is not so large as to
occasion great protrusion beneath the pec-
toral muscle, and the clavicle so long as
to throw the shoulder well back, it should
be  preferred;  but  under  other  circum-
stances, the method of Langenbeck  and
Chelius, as modified  by Bujalsky  and
Manec,  should be selected,—especially as
the division of the fibres of the pectoral
muscle is of comparatively little moment,
when put in competition with the risk of
injuring the axillary vein and nerves in
attempting to pass the  ligature in the
method  proposed by Lisfranc.
   After the ligature is  drawn, the lips of
the wound are brought together in the
usual way, and the subsequent treatment
conducted upon the general principles laid
down in the article Aneurism (q. v.). The
circulation is carried on through the col-
lateral vessels, — especially  through the
free anastomoses between the supra sca-
pular, transverse cervical, and subscapular
branches.
   As  regards  the  application of the me-
thod  of Brasdor, of tying the artery on
 the distal side of the tumour, to this ves-
 sel, a sufficient  number of facts have not
 been collected to justify any conclusion.
 It  should, of course, only be resorted to
 when the  aneurism is  situated so high as
 to  render it impracticable to tie the sub-
 clavian between, or on the outer side of,
 the scaleni muscles.   The case in which
 Dupuytren performed this  operation, it
 has already been  stated, terminated fa-
 tally.
   Bibliography.—The several treatises on Sur-
 gery, and the bibliographical record under An-
 eurism and Arteries.
    9. Aneurismal Varix of the Axilla.  It
 was  remarked  above,  that  a wound in-
 flicted  upon  the axillary region, might
 implicate the artery and its corresponding
 vein,  in such a way as to establish a com-
 munication  between  them,  and  lead to
 the development of an aneurismal varix.
 Whenever such communication is estab-
lished, the artery projects its blood, with
great force, through  the  solution of con-
tinuity into the vein, and the coats  of the
latter being too yielding to resist the dis-
tending influence of the  column of blood,
it becomes dilated into an aneurismal va-
rix of  variable magnitude,  which  may
even extend some distance down the arm.
The  characters of this  form of disease
having been furnished in the article An-
eurism, it will be sufficient at present to
indicate a few cases  in which it was de-
veloped in the axillary artery, and  in con-
sequence of injuries inflicted upon this
region.  Two cases of this kind have been
reported by Larrey.  The  first was an
invalid, in whom an aneurismal varix su-
pervened upon a sword-wound of the ax-
illa.  The whole of the veins of the arm
became  so much dilated, that when  the
member was suffered to hang by the side,
the whole of them were rendered  turgid,
and those  which were  most  prominent
were affected with pulsations isochronous
with those of the arteries. (Mem. de Chi-
rurg. Militaire.  IV. 341.)   Another in-
stance, still more interesting, fell under
the observation of the same individual.  A
grenadier received,  in  a  duel, a  sabre-
wound, which penetrated near the attach-
ment of the sterno-cleido-mastoid muscle
of the left side, ranged obliquely,  and di-
vided a portion of that muscle, the scale-
nus, the subclavian artery and vein, and
probably also  a greater portion  of the
brachial plexus. An alarming hemorrhage
took place immediately; the patient reel-
ed, and  fell to the ground  in a state of
syncope, in which he remained for some
 time,  apparently dead.  The  assistants
 made pressure in the  situation  of the
 wound,  and employed  means to restore
 animation.  When Larrey saw the indi-
 vidual on the succeeding morning, he was
 as cold as marble, and presented every in-
 dication of approaching death.  The he-
 morrhage, however, had ceased;  but tlie
 clavicle was effaced by  a considerable tu-
 mour, which was manifest both above and
 below it and pulsated isochronously with
 the artery.  There was also a singular
 rustling sound along the course of the ax-
 illary vein, analogous to that produced by
 the passage  of water through a tortuous
 metallic tube.   The arm was cold, sense-
 less, motionless, and  without pulse; and
 the pulsation of the other arm was small,
 nervous, and scarcely perceptible.   The
 edges of the wound were drawn together
 by adhesive strips,  over which were  ap-
 plied cloths wet with  cold camphorated
 wine.   In the evening, the jugular vein 
AXILLA.—AZYGOS.
539
was  greatly  distended, and  pulsated;—
next morning, the pulsation of the tumour
had increased,  and on the day following
this, the pulsation of the jugular had be-
come so great, associated with evidences
of strong  cerebral determination,  that it
was opened,  with the  view of emptying
the vessels of the brain.  The blood was
thrown out in jets, and exhibited all the
characters of arterial blood. By the eighth
day, the wound was cicatrized; the veins
of the arm became distended on the tenth
day;  the  heat and sensibility were re-
stored as far down as the elbow; and pul-
sations were  perceptible in the cephalic
vein.   By the twentieth day, the tumour
had entirely disappeared ; but the rustling
sound, and the pulsations of the veins of
the neck and arm, continued.  The arm,
however,  gradually regained its powers,
and by the fifty-fifth day, slight pulsation
was  perceptible in the radial and ulnar
artery. (Larrey. Clinique Chirurgicale.
III. 139.  Paris, 1830.)
  A third case has been reported by Du-
puytren.   The accident took place in a
young  man who was wounded with shot,
the latter  implicating the axillary artery
and vein.   In this instance, there was a
peculiarity, which though previously  no-
ticed by Scarpa,  does not generally exist
in aneurismal varix.  Besides  the  great
dilatation  of the vein  resulting from  the
communication established between it and
the artery, there was also a false consecu-
tive pulsating aneurism, situated between
the two vessels. (Dupuytren.  Traite des
blessures par armes de guerre, &c.  II.
78. Paris, 1834.)
  The treatment of aneurismal varix must
be regulated by the circumstances  of the
case.   Often,  there is not sufficient in-
convenience  experienced, or danger in-
curred,  to call for a difficult  and dan-
gerous operation.  Cold, with astringent,
slightly exciting,  lotions, to the part, in
the early  stage of the disease, and pro-
perly regulated support, maintained by a
compress and bandage, will generally suf-
fice to prevent  the rapid progress  of the
disease, and will sometimes effect a cure,
or so mitigate the morbid condition of the
veins of the arm  and axilla, as to destroy
the principal  source of uneasiness and ap-
prehension.  Should the aneurismal varix,
however, become very large, so as to in-
terfere with,  or destroy,  the use  of the
  vol. n.          50
limb; or should there be associated a false
consecutive aneurism,  disposed to termi-
nate  unfavourably, — then an operation
cannot be dispensed with.  This should be
done, by making an incision upon the ar-
tery, above and below the tumour, and se-
curing it in each situation,  so  as to leave
the aneurism untouched. (See Aneurism.)
                        E. Geddings.
   AXILLARY.  Appertaining to the ax-
illa.
   Axillary Artery, a continuation of the
subclavian, comprised  between the infe-
rior margin of the second rib and the outer
edge  of the fold  of the arm-pit (See II.
565, and II. 344.)
   Axillary Vein,  a  continuation of the
brachial veins; it corresponds  to the axil-
lary artery. (See II. 566, and  Veins.)
   Axillary Nerve,  a branch  of the  bra-
chial  plexus.  (See II. 567,  and Nerves.)
   Axillary Glands, lymphatic glands of
the arm-pit.  (See II. 567, and Lymph-
atics.)                          I. H.
   AXIS.  (From o&ov, axis.) A right line
passing through the centre of an object.
It has also been applied to the  second ver-
tebra of the neck, from its being a kind of    ,,
axis upon which the head turns.  I. H.
   AXUNGIA.   (See Fat.)
   AZEDARACH.  (See Melia.)
   AZOTE.  (From a, priv. and &t,, life.)
Thus named because  supposed to be de-
structive of life.   It possesses, however,
no positively deleterious qualities, though
incapable  of supporting life.  (See Nitro-
gen.)                           I. H.
   AZYGOS.   (From  a priv. and £170$,
equal.)  Unequal, without a fellow. Seve-
ral single parts are so denominated.
  Vena azygos.  (Veine prelombo-thora-
cique. Chaussier.) This name was given
by Galen to a vein which arises from the
inferior vena cava or one of its branches,
and passing up on the  right side  and an-
terior part of the spine, terminates in the
superior vena cava where it penetrates
the pericardium.
   Semi azygos.  ( Veine petite prelombo-
thoracique. Chaussier.) This vein passes
up on the left side of the spine, and pre-
sents  in miniature a similar arrangement
to that of the vessel just noticed.
   Azygos  muscle, a muscle of the uvula
(q. v.).
   Azygos process, a process of the sphe-
noid bone.  (See Bones.)         I. H.
END OF  THE  SECOND  VOLUME. 
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